Anosognosia and Denial: Their Relationship to Coping and Depression in Acquired Brain Injury Kathleen Bechtold Kortte Southern Illinois University at Carbondale and Johns Hopkins University Stephen T. Wegener Johns Hopkins University Kathleen Chwalisz Southern Illinois University at Carbondale Objective: To evaluate relations among denial, anosognosia, coping strategies, and depression in persons with brain injury. Study Design: Correlational. Setting: A Midwest residential, post–acute brain injury rehabilitation center. Participants: Twenty-seven adults with brain injury. Measures: Clinician’s Rating Scale for Evaluating Impaired Self-Awareness and Denial of Disability After Brain Injury, COPE, Beck Depression Inventory—II. Results: Denial and anosognosia were related and co-occurred. Use of process coping strategies was associated with greater use of problem-focused coping strategies. Higher levels of denial were associated with greater use of avoidant coping strategies, and greater use of these coping strategies was related to higher levels of depression. Conclusions: Individuals primarily in denial and individuals primarily anosognosic differ in the coping strategies they institute. Avoidant coping strategies are used more frequently by individuals in denial, and use of these strategies is associated with higher levels of clinical depression. Over the course of recovery from brain injury (BI), individuals are faced with dramatic changes in themselves and their lives. They must cope with cognitive and functional impairments that may compromise their pursuit of employment, parenting, and relationship goals (Godfrey, Knight, & Partridge, 1996). These sudden changes are frequently accompanied by significant emo- tional reactions, such as anxiety, depression, or a catastrophic reaction (for a review, see Prigatano, 1999). In the stress-appraisal coping model of BI recovery, Godfrey et al. (1996) proposed that responses to stressors are mediated by the individual’s “insight of the magnitude of the demands they face [and] their competency to meet these demands through the appli- cation of coping skills” (p. 31). In order for coping strategies to be instituted, the individual must first perceive and acknowledge that a threat has been posed. It has been well established that many individuals with BI lack awareness of their injury, have reduced insight into their impairments, or minimize the severity of their neuropsychological symptoms (for a review, see Prigatano & Schacter, 1991). Reduced awareness may be rooted in neurological dysfunction (anosognosia) and/or may reflect psychological processes to pre- serve self-image and prevent psychological distress (Godfrey et al., 1996). One psychological process of adaptation that has been observed in survivors of BI is denial. Denial is conceptualized as an unconscious defense mobilized against the painful realization of the implication of one’s condition, as well as potential prognosis (Antonak, Livneh, & Antonak, 1993; Prigatano et al., 1986; Wein- stein & Kahn, 1955). Denial allows for avoidance of emotional distress by limiting awareness of BI-related impairments. Unawareness of impairments has been found to limit the effec- tiveness of rehabilitation (Nockleby & Deaton, 1987; Youngjohn & Altman, 1989). Individuals who are unaware of their impair- ments are more likely to refuse to participate in therapy (Diller & Gordon, 1981; Nockleby & Deaton, 1987), tend to take on too much responsibility, and do not ask for help when needed (Heaton & Pendleton, 1981). Clinical observations suggest that survivors of BI who are unaware may take on work tasks that are too difficult, given their residual impairments, resulting in safety problems, task failure, or job loss (Adamovich, Henderson, & Auerbach, 1985). Unawareness appears to diminish rehabilitation participation and outcome, but it is unclear whether the unawareness is rooted in a neurological impairment (anosognosia), a psychological reaction (denial), or a combination of the two. It has been theorized that individuals using psychological denial can be differentiated from those with neurologically based un- awareness by observing the individuals’ behaviors. Prigatano Kathleen Bechtold Kortte, Department of Psychology, Southern Illinois University at Carbondale, and Department of Physical Medicine and Re- habilitation, Johns Hopkins University; Stephen T. Wegener, Department of Physical Medicine and Rehabilitation, Johns Hopkins University; Kath- leen Chwalisz, Department of Psychology, Southern Illinois University at Carbondale. The work reported in this article was completed by Kathleen Bechtold Kortte in partial fulfillment of the requirements for a doctoral degree in clinical psychology at Southern Illinois University at Carbondale. We thank the Center for Comprehensive Services, The Mentor Network, Car- bondale, Illinois, for their support of this research in their facility. We also appreciate Susan Alstat, Michelle Vaughn, Cori Maynor, Laura Jung, and Tina Carpenter for their assistance in data collection and Lynley Meinert for her constructive review of this project as it was conducted. Correspondence concerning this article should be addressed to Kathleen Bechtold Kortte, PhD, who is now at the National Rehabilitation Hospital, Psychology Service, 102 Irving Street, NW, Washington, DC 20010-2949. E-mail: kathleen.kortte@medstar.net Rehabilitation Psychology 2003, Vol. 48, No. 3, 131–136 Copyright 2003 by the Educational Publishing Foundation 0090-5550/03/$12.00 DOI: 10.1037/0090-5550.48.3.131 131