Neuropsychological Rehabilitation

An International Journal

ISSN: 0960-2011 (Print) 1464-0694 (Online) Journal homepage: http://www.tandfonline.com/loi/pnrh20

A biopsychosocial investigation of changes in self-

concept on the Head Injury Semantic Differential
Scale

Avneel Reddy, Tamara Ownsworth, Joshua King & Cassandra Shields

To cite this article: Avneel Reddy, Tamara Ownsworth, Joshua King & Cassandra Shields
(2015): A biopsychosocial investigation of changes in self-concept on the Head Injury Semantic
Differential Scale, Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2015.1114499

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Published online: 25 Nov 2015.

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 NEUROPSYCHOLOGICAL REHABILITATION, 2015
http://dx.doi.org/10.1080/09602011.2015.1114499

A biopsychosocial investigation of changes in self-

concept on the Head Injury Semantic Differential Scale
Avneel Reddy, Tamara Ownsworth, Joshua King and Cassandra Shields
School of Applied Psychology and Menzies Health Institute Queensland, Griffith University, Mt
Gravatt, Australia

ABSTRACT
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This study aimed to investigate the influence of the “good-old-days” bias,

neuropsychological functioning and cued recall of life events on self-concept
change. Forty seven adults with TBI (70% male, 1–5 years post-injury) and 47
matched controls rated their past and present self-concept on the Head Injury
Semantic Differential Scale (HISD) III. TBI participants also completed a battery of
neuropsychological tests. The matched control group of 47 were from a sample of
78 uninjured participants who were randomised to complete either the Social
Readjustment Rating Scale—Revised (cued recall) or HISD (non-cued recall) first.
Consistent with the good-old-days bias, participants with TBI rated their pre-injury
self-concept as more positive than their present self-concept and the present self-
concept of controls (p < .05). More positive pre-injury self-concept ratings were
related to lower estimated premorbid IQ and poorer verbal fluency and delayed
memory (p < .05). For uninjured participants, cued recall, life events and event
appraisals each accounted for unique variance in self-concept change (p < .01) after
controlling for negative affect. The cued recall group rated their past self-concept as
significantly more negative than the non-cued group (p < .01). Overall, the good-
old-days bias, neuropsychological functioning and cued recall influenced reports of
self-concept change by affecting retrospective ratings of past self-concept. Further
research is needed to investigate the impact of contextual cues on self-concept
change after TBI.

ARTICLE HISTORY Received 21 May 2015; Accepted 23 October 2015

KEYWORDS Self-concept; Traumatic brain injury; Neuropsychological functioning

Introduction
Traumatic brain injury (TBI) is a leading cause of disability that has a peak incidence
during the transition from adolescence to adulthood (Bryan-Hancock & Harrison,
2010). This is a key life period during which individuals establish their career, indepen-
dence and adult relationships (Harter, 2012). As such, sustaining a TBI during early adult-
hood can have a major impact on individuals’ developing sense of self. There is
considerable evidence from qualitative and quantitative research that people with TBI
mainly experience negative changes in self-concept (Beadle, Ownsworth, Fleming, &
Shum, 2015; Levack et al., 2014; Nochi, 1998; Ponsford, Kelly, & Couchman, 2014;
Tyerman & Humphrey, 1984). In a recent systematic review, Beadle et al. (2015) found

CONTACT Tamara Ownsworth t.ownsworth@griffith.edu.au

© 2015 Taylor & Francis
 2 REDDY, OWNSWORTH, KING AND SHIELDS

that the discrepancy between pre-injury and present self-concept ratings was positively
associated with emotional distress (Cantor et al., 2005; Carroll & Coetzer, 2011; Wright &
Telford, 1996). However, self-concept change was not significantly related to severity of
TBI or cognitive impairment. Further, self-concept ratings did not significantly differ
between TBI and orthopaedic or trauma control samples (Beadle et al., 2015). Overall,
these findings indicate the need to investigate psychosocial factors influencing
reports of self-concept change after TBI.
Self-concept, or the generalised thoughts and feelings a person has about him or
herself across different domains (e.g., physical, work/study, family/social and
emotional/behavioural), is an inherently subjective construction (James, 1890; Rosen-
berg, 1965). Developmental theorists propose that self-concept forms in a hierarchical
manner with lower-level or situation-specific self-perceptions having a bottom-up influ-
ence on domain-specific (e.g., physical, cognitive, emotional, behavioural, social/family)
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self-concepts. According to their subjective weightings of importance, these self-

concept domains influence a person’s global self-concept (Harter, 2012; Marsh, Byrne,
& Shavelson, 1992). When measured prospectively in the general population, global
self-concept tends to be relatively stable across the lifespan (Orth, Trzesniewski, &
Robins, 2010). However, self-reported psychological characteristics are susceptible to
contextual influences (Markus & Kunda, 1986).
Social neuroscience accounts propose that sense of self is dynamically shaped by
biological and socio-cultural factors (Ownsworth, 2014). In terms of biological influ-
ences, brain damage can disrupt the neural mechanisms and cognitive processes sup-
porting the experience of self and interactions between self and the world (Feinberg,
2011; Stuss, 2007). To date, the role of neuropathology in self-concept change after
TBI has received only limited empirical support. For example, Ponsford, Downing,
et al. (2014) found that people with TBI rated their global self-concept and social,
family, academic, and personal self-concept as significantly poorer than healthy con-
trols. Yet, in studies employing orthopaedic or trauma control samples, self-rated
psychological attributes were similar for people with TBI and controls (Beadle et al.,
2015). Further, neuro-cognitive factors, such as injury severity, (Vickery, Gontkovsky, &
Caroselli, 2005), neuropsychological deficits (Cooper-Evans, Alderman, Knight, & Oddy,
2008; Doering, Conrad, Rief, & Exner, 2011) and objective functional status (Ellis-Hill &
Horn, 2000; Secrest & Zeller, 2007), have not been found to account for self-concept
changes after brain injury. Paradoxically, there is some evidence that people with
more severe TBI and greater cognitive impairment report more positive self-concept
(Carroll & Coetzer, 2011; Cooper-Evans et al., 2008; Jones et al., 2011). For example,
Jones et al. (2011) found that people with severe brain injury were more likely to per-
ceive that their injury had made them stronger as a person.
Psychosocial accounts of self-concept change after TBI emphasise how the conse-
quences of the injury and changes in life circumstances (e.g., loss of relationships,
social roles and occupational activities) can alter people’s sense of inner sameness, or
subjective understanding of who they are (Douglas, 2013; Ownsworth & Haslam,
2016). Using grounded theory, Levack et al. (2014) conceptualised self-identity after
TBI as an individual’s view of him or herself as an integrated and valued person. This
encompassed three inter-related levels; namely: (1) Self-coherence, or feeling whole,
in charge of oneself and a sense of completeness; (2) Feeling respected, validated
and accepted by others; and (3) Having a valued place in the world, or satisfaction
with roles, relationships and productivity (Levack et al., 2014). This account suggests
 SELF-CONCEPT CHANGES AFTER TBI 3

that self-concept after TBI is linked to perceptions of self-continuity and validation

within one’s social context (see also Gracey et al., 2008).
Due to the recognised influence of context on self-identity, it is important to consider
how the approach to assessment and contextual cues might influence reports of self-
concept change. The most common approach to assessing the impact of TBI on self-
concept involves obtaining retrospective ratings of past (pre-injury) self-concept and
comparing these with present (post-injury) self-concept ratings (Cantor et al., 2005;
Carroll & Coetzer, 2011; Tyerman & Humphrey, 1984; Vickery et al., 2005; Wright &
Telford, 1996). The Head Injury Semantic Differential Scale (HISD) was specifically devel-
oped for measuring changes in emotional and behavioural self-concept after TBI and
has been used extensively in research (e.g., Carroll & Coetzer, 2011; Ellis-Hill & Horn,
2000; Tyerman & Humphrey, 1984; Vickery et al., 2005; Wright & Telford, 1996). The
HISD requires people initially to rate their pre-injury self-concept according to 18
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bipolar psychological attributes (e.g., of value–worthless, in control–helpless), and

then rate their present self-concept on the same set of attributes. The total difference
between these ratings indicates level of self-concept change or self-discrepancy
(Tyerman & Humphrey, 1984). Due to reliance on retrospective ratings of pre-injury attri-
butes, reports of self-concept change on the HISD are susceptible to various biases.
The “good-old-days” bias (Gunstad & Suhr, 2001) has been found to influence retro-
spective reports of pre-injury health problems. This bias refers to people’s tendency
after a negative event (e.g., injury) to view themselves more positively in the past
and underestimate problems experienced prior to the event, which, in turn, inflates
reports of problems after the event (Gunstad & Suhr, 2001, 2004). In support of this
bias, people with TBI have been found to rate their pre-injury functioning as significantly
better than healthy control participants’ current functioning (Iverson, Lange, Brooks, &
Lynn Ashton Rennison, 2010; Lange, Iverson, & Rose, 2010; Yang et al., 2014). Despite
these findings, the influence of the good-old-days bias on reports of self-concept
change after TBI has yet to be investigated.
Retrospective reporting of personal attributes is also influenced by access to and
organisation of self-knowledge, which is supported by cognitive control and memory
processes (Fotopoulou, 2008; Ownsworth, 2014). The self-memory system (SMS) frame-
work by Conway and Pleydell-Pearce (2000) proposes that how we see ourselves at a
given time point is a motivated construction drawing upon autobiographical knowl-
edge organised around life-defining themes, and supported by executive control pro-
cesses that influence the formation and accessibility of memories congruent with
one’s goals. Drawing on this framework, neuropsychological impairment may alter
how people view themselves in the past, which in turn influences their experience of
self-discrepancy. Due to a lack of prior research specifically investigating this notion,
a broad range of neuropsychological processes were examined as potential correlates
of self-concept ratings in the present study.
Common sources of response bias for the general population include social desirabil-
ity and mood (Vigil-Colet, Morales-Vives, & Lorenzo-Seva, 2013; Watkins, Vache, Verney,
& Mathews, 1996). Ratings of mood and self-concept have been found to be highly cor-
related (see Cantor et al., 2005; Carroll & Coetzer, 2011). Additionally, self-ratings of
psychological attributes may be influenced by contextual cues (Markus & Kunda,
1986; Thoits, 1991). As part of the assessment or therapy process, people with TBI are
often asked to reflect on their pre-injury selves and changes in their abilities and life cir-
cumstances (Ownsworth, 2014). Cued recall of life events or “identity-relevant
 4 REDDY, OWNSWORTH, KING AND SHIELDS

experiences” (Thoits, 1991) may affect self-perceptions in a negative or positive manner,

as influenced by how people reconstruct events in memory and appraise their personal
significance (Conway, 2005; Conway & Pleydell-Pearce, 2000; Folkman, 1997). The
increased accessibility of cued memories may contribute to self-discrepancies
between one’s past and present self-concept (Higgins, 1987). A typical approach to
measuring life events is to ask participants to endorse the presence and frequency of
significant life events over the last 12 months (Holmes & Rahe, 1967; Monroe, 2008).
It is well recognised that subjective appraisals of events determine their psychological
impact (Folkman, 1997; Taylor, 1983), and thus event appraisals are important to
examine as potential moderators of self-concept change.

The current study

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The broad objective of this research was to investigate neuropsychological and psycho-
social factors associated with self-concept change as measured by the HISD. The first
aim was to investigate the influence of the good-old-days bias on self-concept
change after TBI. It was hypothesised that participants with TBI would rate their
present self-concept as more negative than their past self-concept, and also rate their
past self-concept more positively than the present self-concept ratings of uninjured
controls. A second exploratory aim was to examine associations between measures of
neuropsychological functioning and self-concept ratings for participants with TBI.
As an initial step towards understanding the impact of cued recall of life events on
ratings of self-concept change on the HISD, an experiment with uninjured participants
was conducted. This involved systematically varying the order of administration of a
measure of life events (Social Readjustment Rating Scale—Revised; SRRS-R) and the
HISD. It was hypothesised that participants in the cued recall group (i.e., SRRS-R first)
would report greater self-discrepancy or changes in self-concept than the non-cued
group (HISD first). The impact of life events and moderating influence of event apprai-
sals was also examined.

Method
Participants
A sample of 47 participants with TBI (14 females and 33 males) was recruited in the
context of a broader study examining factors related to emotional status after TBI
(Shields, Ownsworth, O’Donovan, & Fleming, 2015). Participants were eligible for the
broader study if they were aged 18–65 years, had a medical diagnosis of TBI at least
12 months ago and resided within a four hour drive from the metropolitan area. Of
the 73 eligible individuals invited to participate, 47 consented and completed the
HISD and the entire neuropsychological test battery. Three participants were excluded
from the original sample of Shields et al. (2015) due to missing data on the neuropsy-
chological tests. A comparison of the 47 TBI participants and the eligible participants
who did not participate (n = 26) indicated that current participants were typically
older (mean age of 42.79 years, versus 33.5 years). The gender (70–75% male), causes
of TBI (49–50% traffic accidents) and severity of TBI (77–86% severe TBI) characteristics
were similar. The demographic and injury characteristics of the TBI sample are pre-
sented in Table 1. As shown, time since injury varied from 12 to 65 months and most
participants had sustained a severe TBI (86.3%).
 SELF-CONCEPT CHANGES AFTER TBI 5

A sample of 78 uninjured participants was recruited from a university subject pool

and the general community through the researchers’ social networks. Participants
from the researchers’ social networks were contacted through e-mail or Facebook
and subject pool participants responded to an advertisement placed on the subject
pool website. Control participants were at least 18 years of age and had no history of
neurological illness or brain injury. The sample comprised 39 females and 39 males
(age M = 32.85 years, SD = 13.55) with a mean level of education of 14.66 years (SD =
2.57). A subsample of 47 uninjured participants was matched to the TBI sample on
age and gender (see Table 1). Controls had a higher level of education (p < .05);
hence, years of education was treated as a potential covariate. Figure 1 displays a flow-
chart, indicating the design and recruitment in the current study.
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Measures
Neuropsychological functioning
As previously described by Shields et al. (2015) a battery of neuropsychological tests was
administrated which included a measure of estimated premorbid IQ (National Adult

Table 1 Demographic and injury characteristics for TBI and uninjured control participants.
TBI Group (n = 47) Control (n = 47)
Characteristics N (%) / M (SD), range N (%) / M (SD), range
Age 42.79 (12.86) 39.32 (12.67)
20–61 21–68
Gender
Male 33 (70.2%) 33 (70.2%)
Female 14 (29.8%) 14 (29.8%)
Education (years) 13.28 (3.05) 15.39 (2.51)
6–21 11–22
Relationship status at time of injury
Single 15 (31.9) –
Defacto 4 (8.5) –
Partner 5 (10.6) –
Married 20 (42.6) –
Separated 1 (2.1) –
Divorced 2 (4.2) –
Pre-injury employment status
Employed 45 (95.7%) –
Unemployed/homemaker/retired 2 (4.3%) –
Cause of TBI
Traffic 23 (48.9%) –
Assault 5 (10.6%) –
Sport 7 (14.9%) –
Fall 11 (23.4%) –
Other 1 (2.1) –
Severity of TBI
GCS 10.25 (4.49) –
Duration of PTA (days) 28.99 (24.97) –
TBI Classificationa Mild: 11.4% –
Moderate: 2.3% –
Severe: 86.3% –
Time since injury (months) 36.5 (13.2) –
12–65 –
Note: GCS: Glasgow Coma Scale; PTA: post-traumatic amnesia.
a
Source: Kolb and Whishaw (2007): Mild = PTA < 1 hour or GCS = 13–15/15; Moderate = PTA 1–24 hours or GCS =
9–12/15; Severe = PTA > 24 hours or GCS = 3–8/15.
 6 REDDY, OWNSWORTH, KING AND SHIELDS
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Figure 1. Flowchart detailing research design and recruitment in the current study.

Reading Test–Revised; Nelson & Willison, 1991) and the Repeatable Battery for the
Assessment of Neuropsychological Status (RBANS; Randolph, 1998), the Controlled
Oral Word Association Test (COWAT; Benton & Hamsher, 1976), and the Trail Making
Test (TMT; Army Individual Test Battery, 1944).
RBANS is a cognitive screening tool comprised of 12 subtests that assess the fol-
lowing cognitive domains: Immediate Memory (list learning and story memory),
Visuospatial/Constructional ability (figure copy and line orientation), Language
(picture naming and semantic fluency), Attention (digit span and coding), and
Delayed Memory (list recall, list recognition, story memory, and figure recall).
Scores from each subtest contribute to a total domain score (global cognitive
ability). All scores are converted to age-based standardised index scores (M = 100,
SD = 15).
COWAT (letters F, A & S version) is a measure of verbal fluency, in which participants
are required to produce words following a specific phonemic rule (Benton & Hamsher,
1976). Phonemic fluency tasks rely upon language skills and various executive functions
including generativity, self-monitoring, inhibition, and cognitive flexibility (Henry &
Crawford, 2004; Stuss & Levine, 2002). Poor performance on verbal fluency tasks after
TBI is believed primarily to reflect deficits in executive control (Henry & Crawford,
2004). Age-adjusted Z-scores were calculated using normative data (Tombaugh,
Kozak, & Rees, 1999).
TMT involves two visual scanning tasks that require participants to draw lines con-
necting circles pseudo-randomly printed across a page, according to specific rules
(Lezak, Howieson, Loring, Hannay, & Fischer, 2004). TMT-A requires participants to
connect sequentially numbered circles, whereas TMT-B requires participants to alter-
nate between consecutive numbers and letters. TMT-B taps various executive functions,
including task switching, divided attention, and inhibition (Strauss, Sherman, & Spreen,
2006; Stuss & Levine, 2002). The key index of interest in this study was TMT-B seconds
minus TMT-A seconds, in order to control for basic visual attention and motor control.
Age-adjusted Z-scores were calculated for TMT-B minus TMT-A according to published
norms (Strauss et al., 2006).
 SELF-CONCEPT CHANGES AFTER TBI 7

Self-concept
The Head Injury Semantic Differential (HISD) Scale III (Tyerman & Humphrey, 1984)
consists of 18 bipolar adjective pairs (e.g., calm–irritable) rated on a 7-point scale
(1 = negative pole and 7 = positive pole), with reverse scoring as appropriate. Consist-
ent with standard administration guidelines (see Ownsworth, 2014), participants with
TBI were asked to rate their pre-injury self (6 months prior to their injury) on all attri-
butes, followed by their present self. Uninjured participants were asked to rate their
past self (12 months ago) on all attributes and then their present self. This time
period was selected because it is the same time period for assessing recent life
events on the SRRS-R. It was not possible to match the period of retrospective
recall for past self-ratings between the TBI and uninjured samples due to the
varying time since injury for TBI participants. Further, the key comparison of interest
was between the past self-concept ratings of TBI participants and present self-
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concept ratings of controls.

Scores for past and present self-concept ratings on the HISD range between 18 (very
negative self-concept) and 126 (very positive self-concept). The overall discrepancy
between past and present ratings (i.e., present HISD–past HISD) represents self-
concept change, with negative discrepancy scores indicating negative change in self-
concept. High internal consistency was found on the HISD for the uninjured participants
(Cronbach’s α = .94 for present self; .93 for past self) and TBI participants (Cronbach’s
α = .92 for present self; .88 for past self).

Life events and event appraisals

The Social Readjustment Rating Scale—Revised (SRRS-R; Hobson et al., 1998) com-
prises a list of 51 stressful life events for which participants indicate the frequency
of occurrence during the past year. The frequency of each event (maximum of 4)
is multiplied by the life change unit (LCU) score for that particular item (see
Hobson et al., 1998). Scores are summed to derive a total LCU score. To increase
the detail in memories recalled participants were asked to describe briefly each
life event and record the month it occurred. Participants were also encouraged to
describe “other” life events that were not listed on the SRRS-R. These events were
not used in the calculation of LCUs but served to cue participants’ recall of other per-
sonally salient events.
To assess subjective appraisals of life events on the SRRS-R, participants were asked
to rate the impact of each life event on two separate 11-point scales; one for the positive
impact of the event (0 = no positive impact on me at all now, 10 = extremely positive
impact on me now) and one for the negative impact of the event. Mean appraisal
ratings were calculated for each scale. The rationale for using two scales is based on
research indicating that positive and negative appraisals of stressful events can
co-exist (Folkman, 1997).

Measures of response bias

To examine the potential influence of social desirability and mood state on self-concept
change ratings, the Marlowe-Crowne Social Desirability Scale (MC-SDS; Crowne &
Marlowe, 1960) and Positive and Negative Affect Schedule (PANAS; Watson, Clark, &
Tellegen, 1988) were administered to uninjured participants. The MC-SDS consists of
33 true or false items and measures positive response bias related to social desirability.
 8 REDDY, OWNSWORTH, KING AND SHIELDS

The PANAS consists of 20 items rated on a five-point Likert scale (1 = very slightly or not
at all, −5 = very much) and is used to measure positive and negative affect in the
present moment.

Procedure
Ethical clearance for this study was granted from both hospital and university human
ethics committees. The demographic and injury characteristics, neuropsychological
test data and HISD ratings of TBI participants were collected as part of a study investi-
gating factors related to emotional status after TBI (see Shields et al., 2015). The neurop-
sychological tests were administered during the first assessment session and the HISD
was administered in a second session along with other measures of psychological
functioning. For uninjured participants, demographic information was obtained via a
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brief structured interview. They were randomised to cued recall (SRRS-R before HISD,
n = 38) or non-cued recall (HISD before SRRS-R, n = 40) conditions using a computer-
generated sequence. The PANAS and MC-SDS were administered prior to the HISD
and SRRS-R.

Data analysis
Data analysis was conducted using the Statistical Package for the Social Sciences version
21. Missing data and assumptions for parametric analyses were examined and managed
according to procedures outlined by Tabachnick and Fidell (2012). Independent and
paired samples t-tests were used to test the hypothesis concerning the good-old-
days bias. Associations between HISD ratings and neuropsychological test performance
were examined using Pearson product-moment correlations. Hierarchical multiple
regression analyses were conducted to investigate the influence of cued recall, life
events and event appraisals on self-concept change for uninjured participants. Relevant
covariates (e.g., demographics, mood state and social desirability) were entered in the
first step of the model. Cued recall condition was controlled for in the regression analy-
sis examining the relationship between life events, event appraisals and self-concept
change. The moderating effects of event appraisals on the relationship between life
events and self-concept change (model 1), and cued recall and self-concept change
(model 2) were examined using the PROCESS macro (Hayes, 2013). This macro tested
the significance of two-way interactions in these moderation models in SPSS.

Results
Investigation of the good-old-days bias and self-concept change after TBI
Table 2 displays the descriptive data on the HISD for TBI participants and age- and
gender-matched controls. A preliminary correlation analysis identified that level of
education was not significantly related to HISD self-concept ratings (p > .05). A
paired samples t-test comparing self-concept ratings on the HISD for the TBI
sample identified that their pre-injury self-concept was significantly more positive
than their present self-concept, t(46) = 2.63, p = .012, d = 0.38. Furthermore, TBI partici-
pants rated their pre-injury self-concept as significantly more positive than the
present self-concept of uninjured controls, t(92) = −2.48, p = .016, d = 0.51. There
 SELF-CONCEPT CHANGES AFTER TBI 9

Table 2 Descriptive statistics for past and present self-concept on the HISD for the TBI participants and age-and
gender-matched uninjured controls.
Past self Present self
Sample M SD M SD
TBI 105.68 15.31 97.12 18.73
Control 82.09 21.31 96.62 19.80
Note: Higher values indicate more positive self-concept.

was no significant difference in present self-concept ratings between the TBI and
control samples, t(92) = −.13, p = .90, d = −0.03. The lowest mean score observed in
both groups was the past self-concept ratings of uninjured control participants
(note: this reflects the mean score of uninjured controls in the cued and non-cued
recall conditions).
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As a supplementary analysis, a series of t-tests was conducted to assess whether the

observed differences in self-concept ratings were global in nature across the HISD items,
or were related to specific attributes. Due to the multiple comparisons, a more conser-
vative alpha level (p < .01) was adopted. As shown in Table 3, TBI participants viewed
their pre-injury self as significantly more interested, independent and active (p < .01)
than their present self and the present self of controls. Additionally, TBI participants
rated their pre-injury self as significantly more friendly than the present self of controls
(p < .01).

Associations between neuropsychological functioning and self-concept

ratings
Descriptive statistics for the TBI participants’ neuropsychological profile indicated that
their estimated premorbid IQ was in the average range (M = 99.72, SD = 13.29; range:
71–122). Total standardised scores on the RBANS ranged from 55 to 120 (M = 84.6,

Table 3 Comparisons between self-concept ratings of TBI participants and uninjured controls on the HISD.
HISD Positive Pole TBI Pre-injury M (SD) TBI Present M (SD) Control Present M (SD)
Interested 6.32 (1.13) 4.91 (1.95)** 5.36 (1.70)*
Happy 6.02 (1.38) 5.28 (1.60) 5.45 (1.65)
In control 5.89 (1.57) 5.60 (1.38) 5.19 (1.64)
Relaxed 4.98 (1.94) 4.55 (2.03) 4.51 (1.82)
Satisfied 5.45 (1.89) 5.04 (1.76) 5.06 (1.65)
Hopeful 5.70 (1.77) 5.74 (1.36) 5.60 (1.50)
Confident 5.98 (1.33) 5.32 (1.81) 5.68 (1.30)
Stable 5.74 (1.69) 5.43 (1.72) 5.34 (1.58)
Attractive 5.53 (1.52) 5.04 (1.77) 5.04 (1.35)
Of value 6.23 (0.84) 6.06 (1.11) 5.77 (1.15)
Unaggressive 5.38 (1.81) 5.61 (1.79) 4.96 (1.60)
Calm 5.53 (1.77) 4.98 (1.80) 5.55 (1.53)
Capable 6.38 (0.85) 6.13 (0.95) 5.89 (1.26)
Independent 6.45 (1.10) 5.87 (1.38)* 5.32 (1.53)**
Active 6.51 (1.04) 5.66 (1.67)* 5.38 (1.47)**
Talkative 5.72 (1.57) 4.89 (1.70) 5.21 (1.49)
Friendly 6.55 (0.62) 6.13 (0.99) 5.96 (1.27)*
Patient 5.21 (1.97) 4.87 (1.94) 5.34 (1.55)
Note: Both sets of comparisons relate to the TBI participants’ pre-injury ratings.
*p < .01.
**p < .001.
 10 REDDY, OWNSWORTH, KING AND SHIELDS

SD = 14.37), indicating that participants’ global cognitive status was typically poorer
than age norms. A similar degree of variability was evident for each cognitive domain
on the RBANS, as follows: Immediate Memory (M = 84.51, SD = 19.5; range: 40–126),
Visuospatial/Constructional ability (M = 91.10, SD = 17.3; range: 62–126), Language
(M = 93.63, SD = 14.3; range: 51–132), Attention (M = 83.09, SD = 19.0; range: 49–139),
and Delayed Memory (M = 90.29, SD = 15.7; range: 56–134). Verbal fluency on the
COWAT was also highly variable (total words = 12–71; M = 33.98, SD = 10.98), with stan-
dardised scores ranging from −4.52 to 2.45. Participants typically performed in the
average range on the TMT-A (M = 29.73, SD = 13.4), with a mean age-adjusted Z-score
of 0.12 (SD = 1.3; range = −3.49–1.93). Similarly, performance on TMT-B (M = 68.07, SD
= 27.5) was typically in the average range (M age-adjusted Z-score = 0.08, SD = 1.2;
range: −3.80–2.32). There was more evidence of impairment in task switching, with
average performance on TMT-B minus TMT-A in the lower band of the normal range
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(M age-adjusted Z-score = −.47, SD = 1.5; range = −5.44–1.77).

Table 4 presents the correlations between injury-related and neuropsychological test
variables and self-concept ratings for TBI participants. There were no significant associ-
ations between injury severity and time since injury and HISD ratings (p > .05). However,
lower estimated premorbid IQ and poorer verbal fluency and delayed memory on the
RBANS were associated with higher ratings of past self-concept (r = −.33–.38, p < .05),
with medium effect sizes. Further, individuals with poorer verbal fluency (fewer total
words) reported more negative self-concept changes on the HISD (r = .33, p < .05).

Effects of cued recall, life events and event appraisals on self-concept change
for uninjured participants
As shown in Table 5, uninjured participants typically reported positive changes in self-
concept (HISD discrepancy M = 14.65, SD = 24.20), although discrepancy scores varied
from −39 (negative change) to 84 (positive change). The sample had a mean LCUs of
259.04 (SD = 164.71) which was similar to the mean LCUs for Hobson and Delunas’s
(2001) population-based US sample of 3399 participants (M = 278.0, SD = 422.0). Inspec-
tion of the frequency of the 51 life events, identified that beginning or ceasing edu-
cation (8.83%), changing work responsibilities (8.35%), and change in residence

Table 4 Associations between injury-related and neuropsychological variables and self-concept ratings on the
HISD for TBI participants.
Injury and neuropsychological HISD Past Self- HISD Present Self- HISD
variables Concept Concept Discrepancy
Post-traumatic amnesia .28 .07 −.14
Glasgow Coma Scale −.26 −.18 .02
Time since injury .19 .18 .04
NART −.38* −.13 .15
RBANS-Total −.16 .04 .12
Attention −.09 −.04 .03
Immediate Memory −.24 .06 .19
Language −.01 .16 .14
Visuospatial .09 .11 .03
Delayed Memory −.33* −.14 .08
COWAT −.34* .12 .34*
Trails B-A −.18 .09 .20
*p < .05.
 SELF-CONCEPT CHANGES AFTER TBI 11

Table 5 Descriptive statistics and correlations between psychosocial variables and self-concept change for
uninjured participants (n = 78).
Self-
concept Life Cued Negative Positive Negative Positive Social
change events recall appraisals appraisals affect affect desirability
M 14.65 259.04 4.16 5.14 15.03 31.99 16.36
SD 24.20 164.71 2.02 2.20 5.61 7.45 5.54
Range −39–84 0–756 0–8.5 0–10 10–43 12–49 3–29
Life Events .25*
Cued .30** .02
recalla
Negative −.20 .50** −.12
appraisals
Positive .16 −.16 .08 −.36**
appraisals
Negative −.24* −.05 .01 .17 .11
affect
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Positive .13 −.12 −.01 −.30** .17 −.11

affect
Social .06 −.13 −.01 −.36** .27* −.18 .32** -
desirability
a
0 = non-cued (n = 40), 1 = cued (n = 38).
*p < .05.
**p < .01.

(5.97%), were most commonly endorsed. Greater life events (LCUs) and being in the
cued recall condition was significantly associated with positive changes in self-
concept (p < .05). There were no significant associations between negative and positive
appraisals and self-concept change (p > .05). In terms of response bias, negative affect
on the PANAS was associated with more negative changes in self-concept (p < .05).
Negative and positive event appraisals were significantly related (r = −.36, p < .01). To
reduce the number of regression analyses, the negative event appraisal score was
selected as the moderator variable for subsequent analyses.

Impact of life events and event appraisals on self-concept change

As presented in Table 6, after controlling for negative affect and cued recall condition
(R 2 = .15, p = .002), life events and negative appraisals were significantly related to self-
concept change, ΔR 2 = .13, F(2, 73) = 6.68, p = .002. There was no significant interaction
between life events and negative appraisals (see step 3), ΔR 2 = .01, F(1, 72) = 0.80,
p = .375. Significant unique predictors of self-concept change included life events
(β = .41, p = .001), negative appraisals (β = −.33, p = .007) and cued recall (β = 0.26,
p = .012). Therefore, event appraisals did not moderate the relationship between life
events and self-concept change. Greater life events and less negative event appraisals
were significantly related to positive changes in self-concept in uninjured participants.

Impact of cued recall and event appraisals on self-concept change

Results in presented in Table 7 show that, after controlling for negative affect in step 1
(R 2 = .06, p = .036), cued recall and negative appraisals were significantly related to self-
concept change, ΔR 2 = .11, F(2, 74) = 4.65, p = .012. The interaction between cued recall
and negative appraisals was not significant (see step 3), ΔR 2 = .04, F(1, 73) = 3.14, p = .08.
Cued recall (β = 0.29, p = .008) and negative affect (β = −0.22, p = .046) each accounted
for significant unique variance in self-concept change. Hence, event appraisals did not
moderate the influence of cued recall on self-concept change. Being in the cued recall
 12
REDDY, OWNSWORTH, KING AND SHIELDS
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Table 6 Moderated hierarchical regression of life events and negative appraisals on self-concept change controlling for negative affect and cued recall for uninjured control participants.
95% CI (R 2) 95% CI (B)
Variable R 2
Lower Upper ΔR 2 B SE (B) Lower Upper β t sr2
Step 1 .15** .01 .29 .15**
Negative affect −1.03 0.46 −1.95 −0.118 −0.24 −2.25* .06
Cued recall 14.64 5.12 4.43 24.84 0.30 2.86** .09
Step 2 .28*** .12 .44 .13**
Negative affect −0.71 0.44 −1.58 0.17 −0.16 −1.60 .03
Cued recall 12.50 4.82 2.89 22.12 0.26 2.59* .07
Life events 0.06 0.02 0.03 0.09 0.41 3.47** .12
Negative appraisals −3.97 1.43 −6.80 −1.13 −0.33 −2.78** .08
Step 3 .29*** .13 .45 .01
Life events × Negative appraisals −0.01 0.01 −0.02 0.01 −0.32 −0.89 .01
*p < .05.
**p < .01.
***p < .001.
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Table 7 Moderated hierarchical regression of cued recall and negative appraisals on self-concept change controlling for negative affect in uninjured control participants.
95% CI (R 2) 95% CI (B)
Variable R 2
Lower Upper ΔR 2 B SE (B) Lower Upper β t sr2
Step 1 .06* −.04 .16 .06*
Negative affect −1.03 0.48 −1.98 −0.07 −0.24 −2.14* .06
Step 2 .16** .02 .30 .11*
Negative affect −0.95 0.47 −1.88 −0.02 −0.22 −2.03* .05
Cued recall 14.04 5.15 3.77 24.30 0.29 2.73** .08
Negative appraisals −1.39 1.30 −3.98 1.21 −0.12 −1.06 .01

SELF-CONCEPT CHANGES AFTER TBI

Step 3 .20** .05 .35 .04
Cued recall × Negative appraisals 4.54 2.56 −0.56 9.64 0.47 1.77 .03
*p < .05.
**p < .01.

13
 14 REDDY, OWNSWORTH, KING AND SHIELDS

condition and fewer negative event appraisals were significantly associated with posi-
tive changes in self-concept.
Due to the significant influence of cued recall on self-concept change, a mixed two-
way ANOVA was conducted to examine the effect of cued recall condition on past and
present self-concept ratings. Figure 2 displays the mean and standard error of the mean
for HISD self-concept scores for the cued recall and non-cued recall groups. A significant
interaction was found between cued recall condition and self-concept rating, F(1, 76) =
7.69, p = .007, h2p = .09. The cued recall group had significantly lower ratings of past self-
concept (M = 73.79, SD = 19.95) than the non-cued group (M = 86.65, SD = 20.25), t(76) =
2.82, p = .006, d = 0.64. However, there was no significant difference in present self-
concept ratings between the cued (M = 95.92, SD = 19.02) and non-cued groups (M =
94.20, SD = 19.88), t(76) = −0.39, p = .697, d = 0.09.
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Discussion
This study broadly applied a biopsychosocial framework to investigate neuro-cognitive,
psychological and social contextual factors influencing changes in self-concept on the
HISD. The first aim was to investigate the influence of the good-old-days bias on self-
concept change after TBI. Consistent with the hypothesis, participants with TBI rated
their pre-injury self-concept as more positive than their present self-concept and the
present self-concept ratings of controls. In relation to the exploratory aim, lower premorbid
IQ and poorer verbal fluency and delayed memory were associated with more positive
ratings of past self-concept for TBI participants. An experiment with uninjured participants
identified that cued recall of life events prior to administration of the HISD elicited greater

Figure 2. Mean and standard error of the mean for ratings of past self-concept and present self-concept for
uninjured control participants in the cued recall and non-cued recall groups.
 SELF-CONCEPT CHANGES AFTER TBI 15

reports of positive self-concept change. This enhanced positive self-discrepancy effect

arose because participants in the cued recall condition made more negative retrospective
ratings of past self-concept than those in the non-cued condition.
Overall, the current findings regarding self-concept change align with previous
research indicating that people with TBI tend to view their pre-injury functioning in
an overly favourable light (Iverson et al., 2010; Yang et al., 2014). Interestingly, although
the results broadly support the good-old-days bias, this cognitive bias was not evident
for all psychological attributes. Relative to controls, TBI participants rated their pre-injury
selves as more interested, independent, active and friendly. Such findings suggest that
loss of independence, social interaction and activity participation are more salient with
respect to their pre-injury selves than changes in emotional attributes (e.g., calm,
happy). Notably, Iverson et al. (2010) also found that TBI participants’ pre-injury mood
symptoms (e.g., irritable, sad) were similar to controls’ present ratings. In their systema-
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tic review, Beadle et al. (2015) found that pre-injury and present self-concept ratings
were similar for many attributes and that positive changes (e.g., more mature and
appreciative) were evident in some studies. The present findings provide preliminary
support for the utility of the good-old-days bias for understanding self-concept
changes on the HISD; however, this effect seems to vary according to the salience of
different psychological attributes.
A further key finding was that people with lower premorbid intellectual functioning
and poorer verbal fluency and delayed recall held more positive views of their pre-injury
emotional and behavioural attributes. This lends support to the view that memory and
executive control processes facilitate access to self-knowledge regarding one’s past per-
sonal attributes (Conway & Pleydell-Pearce, 2000; Ownsworth, 2014). Impairments in
delayed memory may signify a loss of autobiographical knowledge, which has pre-
viously been found to disrupt self-coherence in people with dementia (Addis &
Tippet, 2004). Research on confabulation similarly highlights that an inability to remem-
ber experiences in an organised manner contributes to loss of self-continuity and exag-
gerated past reconstructions (Fotopoulou, 2008). Consistent with these accounts, the
current findings suggest that greater difficulty recalling previous experiences contrib-
utes to overly positive views of pre-injury attributes. This finding may have applications
in clinical practice; for example, educating clients on the impact of memory difficulties
on perceptions of their pre-injury selves. The only aspect of neuropsychological func-
tioning significantly related to self-concept change (i.e., level of self-discrepancy) was
executive control as measured by the COWAT. Performance on the COWAT relies
upon language and executive functioning, which are processes implicated in identity
reconstruction (Ylvisaker & Feeney, 2000; Ylvisaker, Mcpherson, Kayes, & Pellett, 2008).
In particular, language impairment has been found to affect “ongoing storying of
self” or the ability to form and maintain a coherent self-narrative linking the past,
present and the future (Shadden & Koski, 2007). Stronger language skills and executive
functioning may also support people to engage in meaningful social roles and activities
that help to maintain a sense of inner sameness despite the changes brought about by
TBI.
The experimental component of this study sought to understand the influence of
cued recall of life events on uninjured participants’ ratings of self-concept change on
the HISD. Interestingly, greater life events (LCUs) and cued recall were related to positive
self-concept changes after controlling for negative affect. Although event appraisals did
not moderate these relationships, participants with higher negative appraisals of life
 16 REDDY, OWNSWORTH, KING AND SHIELDS

events reported more negative self-concept changes after controlling for mood state.
This is consistent with previous studies that demonstrated the influence of stress apprai-
sals on psychological well-being (Folkman, 1997; Linley, Joseph, & Goodfellow, 2008).
The finding that greater life events and cued recall had positive effects on self-
concept change is potentially explained by theories of adaptation to stress (e.g.,
Taylor, 1983), which propose that, following adversity, people are inherently motivated
to find ways to restore their self-esteem. The positive self-concept changes associated
with greater life events may reflect a self-enhancing tendency to see one’s self as
having benefited from challenging life experiences (e.g., changing jobs, moving
house). However, rather than inflating present self-concept ratings, the cued recall of
life events produced a negative bias on retrospective self-ratings that served to accom-
modate positive self-concept changes.
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Clinical implications
A key implication of the present findings is that people with greater impairments in
executive control and delayed memory tend to hold more positive views of their pre-
injury emotional and behavioural attributes. In turn, they may find it harder to assimilate
their past and current self-schemas (i.e., the old and new me) as needed to support self-
coherence (Levack et al., 2014; Ownsworth & Haslam, 2016). However, the findings also
suggest that self-discrepancies are not global in nature; rather, ratings of pre-injury and
present self-concept may be consistent for many attributes. Overly favourable percep-
tions of past self-concept appear most common for attributes related to activity partici-
pation and social interaction. Such findings indicate the importance of exploring
perceptions of pre-injury activities and social groups and the personal meaning
derived from these in therapy. Gracey, Evans, and Malley (2009) similarly advocated
the need to identify and target personal and social discrepancies in rehabilitation to
facilitate the process of adjustment and social re-integration. For people with severe
impairments in executive control and delayed recall it may be beneficial to provide con-
crete opportunities to derive a sense of achievement in everyday activities and to
increase the salience of these experiences (e.g., taking a photograph of a meal prepared
for family and friends).
The significant influence of cued recall on reports of self-concept change in unin-
jured participants highlights the need to consider contextual cues in assessments invol-
ving the HISD and rehabilitation more generally. More specifically, individuals’
perceptions self-concept change, and their ratings of pre-injury attributes in particular,
may be influenced by preceding assessment tasks or questions in an interview. It is
further possible that the cued recall of recent life events (e.g., post-injury achievements
and success in overcoming challenging life experiences) during therapy might temper
overly favourable perceptions of one’s past or pre-injury attributes (i.e., good-old-days
bias). However, some caution is needed in generalising the findings on the effects of
cued recall on HISD ratings for uninjured participants to people with TBI. Unlike the
typical life events reported by uninjured participants (e.g., change of work, education
and residence), TBI often brings about major changes in functioning and lifestyle that
have lifelong consequences. People with TBI may be less likely to see themselves as
having benefited from such changes. Therefore, they are more likely than uninjured par-
ticipants to idealise their past or pre-injury selves, which contributes to negative self-dis-
crepancy. Conversely, for uninjured participants, the cued recall of life events produced
 SELF-CONCEPT CHANGES AFTER TBI 17

a negative bias on retrospective ratings of past self-concept to accommodate positive

self-concept changes.
Although little is known about the impact of contextual cues on self-concept
change for people with TBI, the findings of a pilot intervention by Vickery et al.
(2005) are noteworthy. They evaluated a six session group intervention designed to
enhance self-concept after brain injury. Techniques focused on increasing participants’
knowledge of different aspects of the self (i.e., expanding self-views) and recognition
of the subjective importance of personal attributes to overall happiness (i.e., differen-
tiation). Participants were encouraged to identify negative changes (e.g., concen-
tration difficulties) alongside new or persisting positive self-attributes (e.g.,
compassion for others) to support integration and continuity of self. A comparison
of participants’ ratings on the HISD between sessions 1 and 6 indicated a significant
overall improvement in self-concept, with positive changes most evident for the attri-
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butes of attractiveness, boredom, hopefulness, self-confidence, and cooperativeness

(note: this was the original version of the HISD). Ratings of past self-concept were
not obtained, and thus it is unknown whether participants’ account of their pre-
injury selves was altered by the psychotherapy intervention. Further, the durability
of these self-concept changes was not examined at a follow-up assessment. Overall,
further research is needed to investigate the malleability of self-concept ratings on
the HISD, or the extent to which self-perceptions vary according to the assessment
context and therapeutic strategies. In particular, cued recall of salient positive
events since the injury (e.g., recovery progress and achievements) and identifying
with others in a social group may have positive effects on self-concept, although
this remains to be investigated.
A main limitation of the current study relates to the convenience sampling
approach in which participants with TBI were recruited as part of a broader study. Par-
ticipants were typically older than those in the broader pool of eligible participants,
thus, some caution is needed in generalising the findings. Additionally, participants’
time since injury ranged from one to five years, which meant that the time period
for retrospective ratings of pre-injury self-concept varied. Nonetheless, time since
injury was not significantly associated with HISD ratings or self-discrepancy. Another
key limitation is that current mood state was only controlled for in the analyses invol-
ving uninjured controls. Given the significant association between negative affect and
self-concept change for uninjured controls, it is important to control for mood state in
future TBI research investigating self-concept change. For future research, it is rec-
ommended that a prospective longitudinal investigation of self-concept change be
conducted to examine the influence of the good-old-days bias at early (e.g., pre-dis-
charge) and long-term phases of recovery after TBI whilst controlling for mood
state. Such research could examine both global and domain-specific self-concepts
(Ponsford, Downing, et al., 2014). The concurrent recruitment of an orthopaedic or
trauma control sample in addition to a healthy control sample would help to dis-
tinguish between neuro-cognitive and psychosocial influences on self-concept
change.

Conclusion
Overall, the main novel findings of this study are that reports of self-concept change on
the HISD are influenced by multiple factors, including the good-old-days bias,
 18 REDDY, OWNSWORTH, KING AND SHIELDS

neuropsychological impairment and cued recall of life events. People with TBI were
found to report negative self-concept changes and hold overly positive views of their
pre-injury self-concept, which was most evident for attributes related to activity and
social participation. Conversely, the cued recall of life events for uninjured participants
elicited negative ratings of past self-concept, which served to accommodate positive
self-concept changes. Further research is needed to understand how accounts of self-
concept change after TBI vary according to the assessment context and in response
to therapy interventions.

Disclosure statement
No potential conflict of interest was reported by the authors.
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Funding
The authors would like to acknowledge the support of funding from the Griffith Univer-
sity Behavioural Basis of Health publication scheme.

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