BRAIN INJURY,

2000,

VOL.

14,

NO.

10, 887 905

Coping strategies in patients with acquired brain

injury: relationships between coping, apathy,
depression and lesion location
ARNSTEIN FINSET{ and
STEIN ANDERSSON{
{ Department of Behavioral Sciences in Medicine, University of Oslo, Blindern, Oslo,
Norway
{ The Neuropsychology Laboratory, Sunnaas Rehabilitation Hospital, Nesoddtangen,
Norway
(Received 20 January 2000; accepted 21 March 2000 )
Coping strategies in individuals suffering severe traumatic brain injury (TBI), cerebrovascular accidents
(CVA), or hypoxic brain injury (HBI) were investigated in relation to apathy, depression, and lesion
location. Seventy patients (27 with TBI, 30 with CVA, and 13 with HBI) filled in a coping questionnaire (COPE) and were evaluated with respect to apathy and depression. A comparison sample of
71 students also filled in COPE. Patients coping strategies were similar to the comparison group, but
patients tended to display less differentiated coping styles. A factor analysis indicated two dimensions of
coping in the patient sample; approach oriented and avoidance oriented coping. Approach and
avoidance coping sum scores, based on subscales from the two factors, were positively correlated in
the patient sample, but not in the comparison group. Lack of active approach oriented coping was
associated with apathy, whereas avoidant coping was associated with depression. Coping styles were
not related to lesion location. Apathy was related to subcortical and right hemisphere lesions. In
bivariate analyses, depression was unrelated to lesion location, but, in a MANCOVA, avoidant coping,
apathy and lesion location (left hemisphere lesions) contributed to the variance in positive depressive
symptoms. The consistent relationships between coping strategies and neuropsychiatric symptoms
were interpreted as two dimensions of adaptational behaviour: an active vs. passive dimension and a
depression distress-avoidance dimension.

Introduction
The individual who becomes the victim of a severe traumatic brain injury (TBI),
cerebrovascular accident (CVA), or hypoxic brain injury (HBI) will be faced with a
difficult process of psychological adaptation. He or she may be afflicted with motor,
cognitive, and emotional sequelae as direct consequences of the brain injury, and
must learn to cope with a number of challenges. This adaptational process of the
brain-injured individual may be described in terms of coping behaviour, but there is
surprisingly little research explicitly concerned with the process of coping with brain
injury [1]. Folkman et al. [2] define coping as `the persons cognitive and behavioural efforts to manage (reduce, minimize, master, or tolerate) the internal and

Correspondence to: A. Finset, PhD, Department of Behavioral Sciences in Medicine, University

of Oslo, POB 1111 Blindern, N-0317 Oslo, Norway. e-mail: arnstein.finset@basalmed.uio.no
Brain Injury ISSN 0269 9052 print/ISSN 1362 301X online # 2000 Taylor & Francis Ltd
http://www.tandf.co.uk/journals

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A. Finset and S. Andersson

external demands of the person environment transaction that is appraised as taxing

or exceeding the resources of the person (p. 572).
Coping is a multidimensional phenomenon. Endler and Parker [3] reviewed the
coping literature and came up with 14 different categorizations of coping dimensions implemented in different coping scales in the 1980 1990 period. Many of
these scales include one or more dimensions that represent an orientation toward
the stressor, an approach-oriented coping style, in which active tackling of the stressor
and a positive reinterpretation of the stressful situation are prominent strategies. In
studies of coping behaviour, such active approaches tend to be reported as the
preferred way to handle stressors and problems [4].
Two different alternatives to the active, approach-oriented style of coping may
be conceptualized. First, an individual may relate to stressful events in a passive way,
with a mere lack of active approach coping, expressed as low scores on scales or subscales designed to assess approach-oriented coping, in this paper referred to as a
passive coping strategy. Secondly, approach-oriented coping may also be contrasted
against an orientation away from the stressor, an avoidance dimension, which has
been subdivided into a number of different conceptualizations of avoidance coping
such as denial, behavioural and cognitive disengagement [4], distancing and escape/
avoidance [5], and avoidance and resignation [6]. Avoidant coping is not merely the
lack of approach coping, but may imply an active movement away from the stressful
event. In terms of emotional response, approach oriented coping would be characterized by expression of emotions elicited by the stressor and active search for social
support, passive coping with non-expression of emotions, whereas avoidant coping
would tend to imply a rather defensive focusing and venting on emotions, often
combined with social withdrawal.
Roth and Cohen [7] suggest approach vs. avoidance as the two basic modes of
coping with stress, with historical roots in psychoanalytic and behavioural traditions
as well as in field theory (Lewin). Similar two-dimensional conceptualizations of
dealing with stress, pitting active against passive along one dimension and the degree
of defence or distress along the other, have been suggested by a number of researchers, such as Henry and Stephens [8], Frankenhaeuser (effort vs. distress [9]), and
Ursin et al. (active vs. passive control [10]).
Avoidant coping and distress
In a number of studies, avoidant coping is found to be related to distress and negative
affectivity [11 13]. Such a relationship is confirmed in the few studies in which the
concept of coping with stress is related to distress and depressive mood among
patients who have suffered brain injury [14 16].
Psychological distress, ranging from normal grief reactions to major depression, has
often been reported as common sequelae from or response to CVA [17, 18], as
well as TBI [19]. In a number of studies, an association has been found between
depression and left anterior lesions in CVA [17], as well as in TBI patients [19],
although other studies have failed to replicate these findings [18]. In CVA patients,
the impact of lesion location to the left hemisphere for depressive affect seems to
decrease in the months post-onset, as situational aspects and, possibly, personality
factors gradually become more influential in determining the degree of depression
and distress [20]. Moor and co-workers [14, 15] found that individuals with TBI
sequelae who applied a relatively indiscriminant use of a number of emotion-

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889

focused coping strategies, specifically with high avoidance scores, tended to have
high depression ratings, whereas a cluster of patients characterized by comparatively
higher use of self-controlling and positive reappraisal coping and lower external
locus of control was associated with significantly lower mood disturbances and
physical difficulties. Similarly, Malia et al. [16] found that less use of emotionfocused, avoidance, and wishful thinking coping strategies predicted better psychosocial functioning in a sample of TBI patients.

Passive coping and apathy

Passive coping, as the term is applied in this study, is characterized by a lack of
active, approach oriented coping behaviour. Some patients with acquired brain
injury display conditions characterized by inactivity and loss of initiative, which
has more often been described as neuropsychiatric symptoms than in terms of
coping strategies. Gray et al. [21], for instance, has described negative symptoms in
TBI patients during the first year post-discharge, emphasizing reduced initiative and
social withdrawal. A number of other concepts have also been applied to different
aspects of inactive behaviour in TBI and CVA patients, such as avolition, aspontaniety, and reduced initiative [22], emotional indifference, most typically seen in
patients with right hemisphere lesions [23], loss of drive, and apathy [24]. Blumer
and Benson [25] suggested, almost 25 years ago, the term pseudodepression for a
syndrome seen in patients who not only fail to take the initiative, but who also have
lost interest in active behaviour. Laplane and co-workers have described inertia and
loss of drive in patients who shared the combination of bilateral basal ganglia lesions
and a frontal like syndrome [26], and have suggested the term `loss of psychic self
activation [27] to this syndrome with significant elements of negative symptomatology. A number of the negative symptoms referred to above have, in recent years,
been defined and operationalized in the broad neuropsychiatric syndrome of apathy
[24, 28, 29]. Marin [29] defines apathy as diminished goal directed activity due to
lack of motivation, characterized by diminished goal directed cognition, and overt
behaviour, as well as diminished emotional concomitants of goal directed behaviour
in terms of unchanging and flat affect, lack of emotional responsivity, and absence of
emotional excitement. In a number of studies, apathy has been found to be prevalent in samples of patients who have suffered CVA (most often in the right
hemisphere), TBI or hypoxic brain injury [30 33]. Although often interpreted as
a sign of depression [29], apathy in patients with acquired brain injury has been
distinguished from depression in recent studies [33, 34].
The relationship between negative symptoms or apathy and coping strategies has
been much less extensively studied than the association between distress and avoidant coping, and hardly at all in samples of brain injured individuals. Middelboe and
Mortensen [35] found, in a study of long term psychiatric patients, that few negative
symptoms predicted the total number of coping strategies, indicating a restricted
repertoire of coping and a rather passive coping style among patients with negative
symptoms. Macdonald et al. [36] looked at coping strategies in patients with early
psychosis and found effective coping to be correlated with less severe negative
symptoms. To the authors knowledge there is no research so far linking coping
behaviour to negative symptoms and apathy in patients with acquired brain injury.

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A. Finset and S. Andersson

The present study

The aim of the present study is to investigate coping strategies in patients with
acquired brain injuries. The following questions are addressed:
. What is the pattern of coping strategies in individuals who have suffered TBI,
CVA, or HBI, compared to available information on individuals without
brain injury?
. What is the relationship between coping strategies and the neuropsychiatric
symptoms of apathy and depression? Is passive coping related to apathy and
avoidant coping to depression in a two-dimensional matrix of psychological
adaptation (an active passive dimension along one axis and the degree of
distress and avoidance along the other)?
. Are coping strategies related to location of lesion, or does coping contribute
to the variance in analyses of lesion location effects on apathy and depression?

Methods
Subjects
Seventy patients, 55 males and 15 females, admitted to a rehabilitation hospital, took
part in this study. Mean age was 38.6 years (SD 13:4) ranging from 16 63 years.
Thirty patients had CVA, 27 patients TBI, and 13 patients had suffered HBI due to
cardiac arrest. Mean time from injury to participation in the study was 12.7 months
(SD 11:0). Patients with prior neurological or psychiatric diagnoses were
excluded from the study.
Lesions
All patients had verifiable brain lesions evidenced by cerebral CT, MRI and/or
EEG. Independent assessment of the medical records by the two authors and a
clinical neurologist classified 17 CVA patients as having a focal right hemisphere
(RH) lesion, 11 CVA were classified as focal left hemisphere (LH) damage, and two
had bilateral lesions. Also, TBI patients, when a single unilateral contusion or
haemorrhage evidenced by CT or MRI were present, were classified as focal RH
damage (n 8), LH damage (n 7) or as multifocal bilateral damage (BH, n 12).
Adding CVA and TBI patients gave 24 RH damaged patients, 18 with LH damage,
and 14 patients defined as having bilateral damage. Thirteen patients had subcortical
lesions
Comparison group
The patient sample was compared to a comparison group of 71 normal students, 50
males and 21 females, with a mean age of 25.2 (SD 6:7) years, drawn from a
larger sample of students who had filled in the COPE coping questionnaire (see
below). The student sample was significantly younger than the patient sample
(t 7:53, p < 0:001), and is, thus, described as a comparison group rather than a
control group. In comparisons between the two samples, age is, therefore, included
as a covariate.

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891

Instruments
Coping
All patients, as well as the students in the comparison group, filled in the COPE
questionnaire, developed by Carver et al. [4]. COPE is a theory based inventory,
with six response alternatives ranging from 0 (`I usually dont do this at all) to 5 (`I
usually do this a lot). In the 48 items version applied in this study, the COPE items
were classified into 12 conceptually distinct coping sub-scales or indexes, each index
composed of four items. Carver et al. conducted a factor analysis based on the 12
indexes, and came up with four factors, three of them representing approach
oriented coping in action-oriented, socio-emotional, and cognitive domains, respectively, and a fourth factor representing avoidant coping strategies (denial, behavioural and cognitive disengagement) [4].
In the present study, the internal reliability of the 12 indexes varied from
Cronbachs / 0:56 0.80, three indexes falling below 0.60.
Apathy
The clinician version of Marins Apathy Evaluation Scale (AES) was applied to
quantify degree of apathy [30]. This clinical interview contains 18 items, which
cover the cognitive, emotional, and behavioural aspects of apathy. Each item is rated
on a four step scale. The AES has been validated in different neurological and
psychiatric populations, such as patients with major depression, Alzheimers disease,
stroke and Parkinsons disease [30, 31, 37]. Reliability analyses in terms of internal
consistency, test retest and inter-rater reliability have shown satisfactory results [30].
A cut-off criterion or 34 points or higher on the AES, suggested by Kant et al.
[32] was applied to distinguish between `apathetic and `non-apathetic patients.
In the present study, two subscale scores have been computed from the AES.
One subscale consists of the seven items described by Marin as cognitive aspects of
apathy, in the text labelled Cognitive Apathy. These items refer to the patients
interests in doing things, concerns about their problems, and the notion that getting
things done, seeing friends, etc. is important. Another subscale consists of five
behavioural and two emotional items, labelled Behavioural/ Affective Apathy.
The items refer to the patients emotional excitement, their intensity in approach
to life, and actual performance in a number of activities. Four items classified as
`Other are not included in either of these two subscales.
Depression
sberg Depression
Patients were rated for depression using the Montgomery and A
Rating Scale (MADRS), administered as a clinical interview, containing 10 items
covering different aspects of depressive symptomatology [38]. Each item is rated on
a seven step scale. MADRS is frequently used as a research and clinical tool in
diagnosing depression, and has also recently been applied in research exploring
depression in brain damaged patients, e.g. in stroke [39] and Parkinsons disease [40].
According to conventional criteria, patients with a MADRS score of 6 or less
were considered as not depressed. Scores in the 7 19 range are characterized as mild
depression, 20 34 as moderate depression, and scores from 35 up to the maximum
score of 60 as severe depression [41].
The authors of the present study have recently identified three factors from
MADRS describing different aspects of depressive symptomatology in a patient

892

A. Finset and S. Andersson

sample overlapping with the one described here. One factor was labelled Affective
Symptoms (composed of `Subjectively reported sadness, `Observed sadness and
`Depressive thinking), another factor Somatic Symptoms (composed of
`Disturbed appetite, `Disturbed sleep, and `Inner tension) and a third factor called
Negative Symptoms (`Lack of initiative, `Reduced emotional responsivity and
`Inattention) [33]. These three categories of depressive symptoms, expressed as
the sum of the items composing each category, will be used in the further statistical
analyses in the present paper.
Depression ratings (MADRS) were available for 62 of the patients.
Statistics
Bivariate Pearsons product-moment correlation, as well as partial correlation, were
applied to assess how coping, depression and apathy scores were related to each
other.
In order to extract various dimensions of coping strategies and neuropsychiatric
symptoms, principal component analyses (PCA) with Varimax rotation were conducted.
Between group differences were analysed, applying independent sample t-tests
(comparing patient and student sample), post hoc analyses of individual between
group differences, with Bonferroni corrections, and general linear ANOVA models.
Results
Coping strategies
The means and standard deviations of all 12 COPE sub-scales, both in the patient
sample and in the comparison group, are given in table 1. Both in the patient and
the comparison sample indexes, describing approach-oriented coping strategies,
such as `Active coping and `Positive reinterpretation tended to gain relatively
high scores, while strategies typically expressing avoidance, such as `Denial and
`Behavioural disengagement were less frequently reported. There was, however,
a trend that patients had lower scores than the students in the comparison group.
The mean scores in nine of the 12 indexes were lower in the patient sample, and for
four of them the differences were statistically significant, even when age and gender
was controlled for. The differences were most outspoken for the two indexes on
social support, on which patients reported much less use of seeking instrumental
(F 8:9; p 0:003) and emotional (F 8:0; p 0:005) support than the students
in the comparison group.
On the two indexes, the patient sample had higher mean scores than the comparison group in MANCOVAs in which age and gender were controlled for, the
`Acceptance (F 9:0; p 0:003) and `Behavioural disengagement (F 9:7;
p 0:002) indexes.
In order to investigate to which extent the separate COPE indexes represented
broader patterns of coping strategies, a principal component analysis of the 12
COPE indexes was performed, both in the patient sample and in the comparison
group. In the patient sample, eigenvalues indicated a two-factor solution (table 2).
Factor 1 was composed of the `Active coping, `Planning, `Positive reinterpretation and growth and `Acceptance indexes, as well as the two indexes expressing

Items in the Active Approach sum score.

Items in the Avoidance sum score.

2
0
2
4
0
0
0
0
0
0
0
0
5
0

Min

20
20
20
20
19
20
20
18
15
20
19
18
74
42

Max
11.8
11.3
12.8
13.7
9.3
8.4
6.6
4.4
3.7
6.4
9.0
8.1
45.2
15.6

Patient sample

(4.0)
(4.7)
(4.7)
(4.5)
(4.5)
(4.4)
(4.3)
(4.3)
(4.4)
(4.5)
(4.8)
(3.8)
(14.4)
(10.4)

(SD)
5
4
6
1
4
3
3
0
0
1
4
2
19
3

Min
19
20
20
20
20
19
18
13
10
20
20
17
77
36

Max
13.2
13.0
14.8
11.8
12.8
12.5
9.0
2.8
3.4
9.1
9.4
9.8
53.6
15.1

Comparison sample

(3.0)
(3.6)
(3.1)
(3.6)
(3.8)
(3.7)
(3.4)
(2.7)
(2.9)
(3.8)
(3.3)
(3.5)
(10.7)
(6.7)

(SD)
2.3
6.1
0.8
9.0
8.9
8.0
4.0
9.7
0.1
1.6
0.5
1.1
5.9
0.002

n.s.
0.015
n.s.
0.003
0.003
0.005
0.048
0.002
n.s.
n.s.
n.s.
n.s.
0.016
n.s.

Means and standard deviations on COPE subscales in patient sample (n 70) and comparison sample (n 71). ANOVAs with age and gender controlled for

Active copinga
Planninga
Positive reinterpretationa
Acceptance
Social support (instrumental)a
Social support (emotional)
Mental disengagementb
Behavioural disengagementb
Denialb
Focus on emotionb
Suppressing competing activity
Restrained coping
Active approach sum score
Avoidance sum score

Table 1.

Coping strategies
893

894
Table 2.

A. Finset and S. Andersson

Principal component analysis of coping sub-scales. Eigenvalues of five first factors and rotated factor
matrices. Factor loadings < 40 suppressed

Eigenvalues of 5
1st factor:
2nd factor:
3rd factor:
4th factor:
5th factor:

first factors:
5.2
1.9
1.0
0.8
0.7

Rotated factor matrix:

Factor 1
Active copinga
Social support (instrumental)a
Planninga
Positive reinterpretationa
Social support (emotional)
Acceptance
Mental disengagementb
Behavioural disengagementb
Denialb
Focus on emotionb
Suppressing competing activity
Restrained coping
a
b

Factor 2

0.81
0.78
0.74
0.70
0.63
0.56

0.40
0.57
0.57

0.81
0.79
0.72
0.71
0.64
0.58

Items in the Active Approach sum score.

Items in the Avoidance sum score.

`Seeking social support for instrumental and emotional reasons, respectively. All
these indexes may be said to represent an approach-oriented coping strategy.
The three most typical avoidant coping indexes, `Mental, `Behavioural disengagement and `Denial, as well as `Focusing and venting on emotions, had strong
factor loadings on the second factor, which the authors have chosen to label the
Avoidant Coping factor. The latter index also displayed a medium strong loading on
the approach factor. `Suppression of competing activities and `Restrained coping
exhibited equally strong loadings on both factors.
Two sum scores for each of the two major dimensions of coping which appeared
from the factor analysis were computed. The four COPE indexes with the highest
loadings on each of the two factors were labelled `Approach Coping and
`Avoidance Coping sum scores, respectively. Means and standard deviations of
these sum scores are presented in table 2.
In the comparison group, a factor structure more similar to the one reported by
Carver et al. [4] appeared, with a differentiation of approach-oriented coping in
different domains (Cognitive, behavioural, and socio-emotional).
The correlation between the Approach and Avoidance sum scores in the patient
sample was 0.33 (p < 0:01). When gender, age and neuropsychiatric symptoms
were controlled for in a partial correlation, the positive association between
Approach and Avoidance sum scores reached 0.43 (p < 0:01). The association
was strongest in the hypoxic group. When corresponding coping sum scores
were computed in the comparison sample, they were statistically unrelated
(r 0:04, n.s.). If an alternative, narrower, avoidance score composed of the
three coping indexes with highest loadings on the avoidance factor (table 2), leaving

Coping strategies

895

out `Focusing and venting on emotions (which also has a loading on the approach
factor), a borderline significant negative relationship was found between approach
and avoidance scores (r 0:22, p < 0:10) in the comparison sample when gender
and age were controlled for. In the patient sample, a positive correlation was
upheld, even when the Approach Coping sum score was correlated with the narrower avoidance score.
Apathy and depression
Close to two thirds of the patients (41 patients, 66.1%) had MADRS scores indicating mild depression. Sixteen patients (25.8%) were rated as not depressed, and five
patients (8.1%) as moderately depressed. No patients qualified for the severe depression criterion of 35 points or more on the MADRS.
Forty-three patients (61.4%) were rated as apathetic, and 27 (38.6%) as nonapathetic according to the Kant criteria. Among the apathetic patients, 82.9% were
also rated as mildly or moderately depressed.
Means and standard deviations of the Apathy and Depression scores are given in
table 3. Neither level of depression nor of apathy was significantly related to sex,
age, or level of education.
As expected, the AES and MADRS sum scores were significantly related to one
another, with a Pearsons coefficient of correlation 0.43 (p < 0:001). However,
when the Apathy and Depression scores were broken down in different components, it appeared that the association between the two could be specified to the
correlation between the Behavioural Affective Apathy subscale of the AES and the
Negative Symptoms subscale of the MADRS, which ran as high as 0.72
(p < 0:001). The Cognitive Apathy subscale was neither significantly associated
with the Affective Symptoms (0.20, n.s.) nor with the Somatic Symptoms (0.01,
n.s.) subscales of the MADRS (table 3).
Thus, in order to distinguish apathy from depression, a Positive Depressive
Symptoms sum score was computed, adding the Affective and Somatic
Symptoms. The correlation between Positive Depressive Symptoms sum score
and the Apathy Sum score was 0.18 (n.s.)
Coping, apathy and depression
There were significant negative bivariate correlations between the Approach
Coping Sum score and the apathy scores, which were upheld when the
Depression sum was partialled out. Moreover, there was a significant positive relationship between the Approach Coping sum score and the Somatic Symptoms score
of the MADRS (r 0:26, p < 0:05) in a partial correlation when Apathy was
controlled for. There were no other significant associations between approachoriented coping and the depression score (table 3).
The Avoidance Coping sum score was not significantly related to any of the
apathy measures when depression was controlled for. There were, however, positive correlations between the Avoidance Coping sum score and all measures of
depression (table 3).
To further investigate the relationship between coping, depression and apathy, a
principal component analysis was performed, in which both coping sum scores, the
Apathy sum score, and the Positive Depressive Symptoms score were entered. Two

0
0
0
2

62
62
62
62

70
70

70

Affective symptoms
Somatic symptoms
Negative symptoms
Total depression score

Approach coping
Avoidance coping

Approach coping
score
Avoidance coping

70

51

21

(see table 1)

(see table 1)

9
9
11
31

19
21

Max.

8
8

Min.

3.2
2.5
4.3
10.4

36.0

13.6
13.6

2.3
2.4
2.6
6.0

7.3

2.7
3.0

SD

70.03

0.29*

0.32*

0.26*

0.25

0.04

0.41**

0.18

0.03

70.32*

70.17

0.72***

Negative
Total
symptoms depression

0.07

0.13
0.68***

Somatic
symptoms

70.27*

0.40**
0.45***
0.83***

Affective
symptoms

70.30*

0.25
0.06
0.64***
0.43***

Total
apathy

70.15
0.00
0.24
0.03
0.32*
0.32*
0.30*
0.44**
Partial correlation, controlled for total
Apathy score

0.32*
0.17
0.72***
0.56***

0.91***

Behavioural/
affective
apathy

70.29*
70.23
70.29*
0.01
0.34**
0.24
Partial correlation, controlled for total
Depression score

0.20
0.01
0.44***
0.29*

0.87***

0.69***

Cognitive
apathy

Bivariate correlations

Mean (SD) apathy and depression. Correlational matrix of inter-relationships between apathy, depression and coping sum scores

Cognitive apathy
70
Behavioural/affective 70
apathy
Total apathy score
70

Table 3.

896
A. Finset and S. Andersson

Coping strategies

897

factors emerged, a first factor consisting of avoidance coping and positive depressive
symptoms, both with positive loadings (0.85 and 0.75, respectively), and a second
factor consisting of apathy and approach coping, in which the coping score had a
negative loading (0.83 and 0:75, respectively).
Coping, apathy and depression: relationship to diagnoses and lesion
localization
In bivariate analyses, there were no significant Approach Coping sum score differences, neither between diagnostic nor localization categories. There was a trend for
hypoxic patients to have higher Avoidance Coping sum scores than CVA patients,
with TBI patients in between. Moreover, there was a trend that patients with nonlateralized lesions (sub-cortical or bilateral) had higher Avoidance Coping scores
than patients with either left or right hemisphere lesions. However, in post-hoc
analyses with Bonferroni corrections, these trends did not reach statistical significance.
Apathy scores were significant higher in patients with right hemisphere lesions
and non-lateralized lesions (hypoxic patients and CVA and TBI patients with bilateral lesions) than in left hemisphere patients, and also in hypoxic patients when
compared to CVA patients. Depression scores were neither significantly related to
diagnosis nor to lesion location in bivariate analyses (table 4).
The relationship of coping and neuropsychiatric symptoms to diagnostic and
localization categories: multivariate analyses
A series of analyses of variance were finally conducted to explore the relationship of
coping and neuropsychiatric symptoms to diagnostic and localization categories.
Each of the variables Apathy sum score, Positive Depressive Symptoms score, and
the two coping sum scores were entered as dependent variables in MANCOVAs,
with the other three variables as covariates, and with diagnosis and lesion location as
factor variables. With the neuropsychiatric symptoms as dependent variables,
MANCOVAs were also performed without the coping scores as covariates (table 5).
No significant effect, neither of diagnosis nor of lesion location, was found for
any of the coping sum scores. As covariates, Avoidance Coping and Apathy contributed significantly to the variance of Approach Coping. Correspondingly,
Approach Coping and Positive Depressive Symptoms contributed to the variance
of Avoidance Coping (table 5).
There was no significant effect of diagnosis (figure 1(a)), but a highly significant
main effect of lesion location (F 8:25; p 0:001, figure 1(b) on the Apathy sum
score. This main effect occurred whether the coping scores were included as covariates or not. Approach Coping (F 9:66; p 0:003) and Positive Depressive
Symptoms (RF 7:68; p 0:008) also contributed to the variance.
When the Positive Depressive Symptoms score was entered as a dependent
variable and Apathy sum score as a covariate, there was no significant main effect
of diagnosis, and a rather weak lesion location effect (F 2:4; p 0:102). But,
when the coping scores were also included as covariates, significant main effects of
both diagnosis (F 4:54; p 0:038; figure 2(a)) and lesion location (F 3:50;
p 0:037; figure 2(b)) were found. Patients with left (or to a lesser extent
bilateral) lesions tended to have higher Positive Depressive Symptom scores than

Localization categories
Left hemisphere lesions
Right hemisphere lesions
Bilateral lesions
Subcortical lesions
Total sample

Diagnostic categories
Cerebrovascular accident
Traumatic brain injury
Hypoxic brain injury
Total sample

Table 4.

(SD)

44.5
(17.1)
43.9
(13.4)
49.5
(13.4)
44.2
(14.3)
45.2
(14.4)
No significant
differences

44.1
(16.1)
46.9
(12.8)
44.2
(14.3)
45.2
(14.4)
No significant
differences

Approach coping
sum scores

17.4
20.0
22.9
26.2
21.0

16.8
23.2
26.2
21.0

(11.9)
(10.3)
(16.9)
(16.3)
(13.6)
No significant
differences

(8.2)
(15.9)
(16.3)
(13.6)
No significant
differences

(SD)

Avoidance coping
sum scores
(SD)

30.7
(6.9)
38.1
(6.1)
34.6
(6.0)
40.9
(6.7)
36.0
(7.3)
RH > LH(p=0.002)
SC > LH (p < 0:001)

34.3
(7.2)
35.7
(6.9)
40.9
(6.7)
36.0
(7.3)
HBI > CVA
p 0:017

Apathy
sum scores

10.9
10.6
9.7
9.8
10.4

10.9
10.0
9.8
10.4

(SD)

(6.8)
(6.4)
(6.8)
(6.8)
(6.0)
No significant
differences

(5.2)
(7.2)
(6.0)
(6.0)
No significant
differences

Depression
sum scores

Coping, apathy, and depression sum scores in diagnostic and localization categories. Post-hoc analyses with Bonferroni corrections

898
A. Finset and S. Andersson

Coping strategies
Table 5.

899

Summaries of two-ways MANCOVAs with Apathy. Positive Depressive Symptoms, Approach and
Avoidance sum scales, respectively, as dependent variables
Positive Depressive
Symptoms as
dependent variable

Apathy as dependent
variable
Coping not
included as
covariate

Coping not
included as
covariate

Coping Approach
included as coping as
covariate dependent
variable
F

Avoidance
coping as
dependant
variable

2.3
7.8

0.132
0.007

3.0
8.2

0.091
0.001

1.4
2.4

0.240
0.102

4.5 0.038
3.5 0.037

0.4 n.s.
0.7 n.s.

7.9

0.007

7.9

0.007

0.008
0.003
n.s.

7.7
9.7
0.5

7.7 0.008

0.6 n.s.
8.8 0.005

9.7 0.003 0.5

0.6 n.s.
8.8

8.9
8.9 0.004

Diagnosis
Localization
Covariates
Apathy
Depression
Approach
Avoidance

Coping
included as
covariate

3.5 0.068
0.6 n.s
n.s.
0.005
0.004

patients with right hemisphere or subcortical lesions. Positive Depressive Symptom

scores were highest in CVA patients, and lowest in patients with hypoxic lesions.
Avoidance Coping (F 8:78; p 0:005) and the Apathy sum score (F 7:68;
p 0:008) contributed significantly to the variance, when included as covariates.
Discussion
The present study has investigated coping strategies in a sample of patients with
acquired brain injury in a rehabilitation setting, at an average of 1 year post-onset. In
spite of the positive correlation between approach and avoidance coping, and the
overlap between apathy and depression in the present sample, the hypothesized
pattern of two dimensions of adaptational behaviour was found: first, an active
passive dimension representing the negative association between approach coping

Figure 1.

Estimated Marginal Means (EMM) of Apathy sum score in (a) diagnostic, and (b) lesion localization
categories (based on analyses of variance, see text and table 5).

900

Figure 2.

A. Finset and S. Andersson

Estimated Marginal Means (EMM) of Positive Depressive Symptoms sum score in (a) diagnostic, and
(b) lesion localization categories (based on analyses of variance, see text and table 5).

and apathy, and secondly, a depression distress-avoidance dimension. Whereas

coping strategies were unrelated to lesion location, apathy was related to right
(or subcortical) and positive depressive symptoms to left (or bilateral) hemisphere
lesion, the latter apparent only when apathy and coping strategies were included as
covariates.

Coping strategies
The profile of coping strategies reported by patients was similar to what has been
found in other studies applying the COPE questionnaire [4]. Approach-oriented
coping strategies gained, as a rule, higher scores than strategies indicating avoidance,
such as `Denial and `Behavioural disengagement. This general pattern was true in
both sexes and across diagnostic and localizational categories. There were, however,
some interesting differences between patients and the students in the comparison
group. First, patients in the brain injury sample tended to report less use of approach
oriented coping, and, specifically, less seeking of social support, than students, even
when age and gender differences were controlled for. Secondly, the approach
coping of the patients seemed to be somewhat more uni-dimensional than
among students. The original four-factor solution reported by Carver et al. [4]
was not reproduced. Rather, one single approach factor emerged in the PCA in
the patient sample, whereas, in the student sample, different aspects of approach
coping could be specified, in keeping with Carver et al.s [4] sample. Thirdly, there
was actually a significant positive correlation between the Approach and Avoidance
Coping sum scores in the patient group, as opposed to the comparison group of
students, in which the association between approach and avoidance scores leaned
towards the negative. Consequently, many patients displayed relatively flat coping
profiles. For instance, depressed patients without severe apathy tended to have
rather high avoidance scores, and yet not lower approach scores than other patients.
In fact, somatic symptoms of depression, most notably sleep disturbance, were also
positively correlated to approach coping. The pattern could indicate a relatively
indiscriminate use of avoidant and emotion-focused coping strategies among
depressed patients, a conclusion also drawn by Moore and Stambrook from their
studies [14, 15]. Apathetic patients tended to display low approach scores, but when

Coping strategies

901

depression was controlled for, there was no trend for their avoidance scores to be
high. In fact, some apathetic patients had consistently low scores on most coping
subscales. Taken together, these findings indicate that patients tended to display
somewhat less differentiated coping styles than the individuals in the non-patient
sample.
Apathy and depression
The study confirmed that apathy and depression may be differentiated as distinguishable symptoms in a brain-injured population in terms of separate (affective and
somatic symptoms of depression, and cognitive symptoms of apathy) and shared
symptoms (anhedonia and reduced initiative).
Compared to other studies, the prevalence of depression was moderate in the
present sample. This could be due to the fact that the incidence of depression varies
considerably in the months and years subsequent to brain injury, and is at a relatively
low ebb at about 1 year post-injury, perhaps not least when patients are in an active
rehabilitation programme, which was the case for the patients in the present study
[20]. The low MADRS score could also be due to a conservative application of the
instrument.
There are fewer studies on apathy than on depression in a comparable sample.
The prevalence of apathy in this sample is well in keeping with other recent studies
[31, 32].
Coping, apathy and depression
The relationships between coping and the neuropsychiatric symptoms of apathy and
depression were studied in three different ways in the present study. This study
looked at (a) correlation (bivariate and partial) between coping scores and neuropsychiatric symptoms (table 3), (b) a PCA of coping sum scores, Positive Depressive
Symptoms, and Apathy sum scores, and (c) analyses of variance and co-variance in
which coping and neuropsychiatric symptoms were broken down against diagnostic
and localizational categories (table 5).
Given the positive correlation between approach and avoidant-oriented coping
styles and the somewhat undifferentiated patterns of coping in the patient sample,
one might expect that coping scores would be more related to one another than to
neuropsychiatric symptoms. However, in all the analyses, there is a consistent negative relationship between approach-oriented coping and apathy, and a positive
association between avoidance coping and positive depressive symptoms.
The association between depression, negative affectivity, and avoidant coping is
well documented in the literature [11 13]. In the present study, as in numerous
others, the depressed patients displayed a coping style characterized by elements of
mental disengagement and focusing and venting on emotions, specifically negative
emotions. Such behaviour may, perhaps, be considered as cognitive concomitants of
depressed affect, rather than a different phenomenon that happens to be statistically
related to depression.
The relationship between apathy and coping style is less thoroughly investigated.
The present sample of brain injured patients, many of whom are apathetic, offers an
interesting opportunity to assess self-reported coping strategies among patients with
varying degrees of apathy. Although not surprising, it is interesting to observe that

902

A. Finset and S. Andersson

apathy, characterized by little interest in external events and a low sense of the
importance of the activities of daily living, is consistently associated with a passive
approach to a number of coping behaviours.
In spite of a strong positive correlation between approach and avoidanceoriented coping, as well as considerable overlap between the symptoms of apathy
and depression, a PCA of the two coping sum scores, positive symptoms of depression and apathy, confirmed two dimensions of adaptational strategies in the patient
sample: an active passive dimension represented by approach coping and apathy,
and a dimension of avoidance coping and psychological distress. Dantzer [42] has
discussed a number of similar formulations in the literature, in which the active
passive dimension has been associated with sympathetic activation and the distress
dimension with the activity of the pituitary-adrenal system [8, 10].
Unmasking the effect of lesion location on depression
It was assumed that coping strategies were unrelated to lesion location. This proved
to be true, even in multivariate analyses, where the potential confounding effect of
neuropsychiatric symptoms was controlled for. These findings indicate that coping
strategies are less dependent on specific aspects of the brain injury sequelae than on
psychological factors such as pre-morbid personality and coping repertoire.
Apathy was strongly related to right hemisphere and subcortical lesions in all
analyses, both bivariate and multivariate, confirming the strong organic component
in this neuropsychiatric symptom [29].
The relationship of depression to location of lesion was more complicated. First,
the depression sum score proved to be too confounded with apathy to be useful in
investigating the relationship of depression to localization. Moreover, even when
positive depressive symptoms were applied as the independent variable, there was
no association with lesion location in bivariate analyses. However, the inclusion of
apathy and coping strategies as covariates unmasked the effect of lesion location,
indicating a vulnerability to develop positive depressive symptoms in patients with
left hemisphere lesions. The fact that both apathy and coping strategies had to be
included as covariates in order to show a lesion location effect may indicate that, for
depression, the role of the brain lesion and its localization seems to be weaker than
for apathy. The most reasonable interpretation is to consider affective symptoms
after brain injury to be caused by an interplay of organic (LH lesion) and psychological factors, in the present study represented by avoidant coping style.
Even when the affective disorder component and the negative symptoms are
separated in the Positive Depressive Symptoms and Apathy scores respectively, they
still overlap. By controlling for one another in variance analyses, these two core
classes of symptoms are differentiated and isolated, and interestingly found to be
associated with different lesion locations, even with the crude laterality measure
applied in this study. A possible interpretation of these findings is to consider the
two most important symptoms in depression [43] positive (depressed mood) and
negative (loss of interest or pleasure) symptoms to be related to different pathophysiological mechanisms. There is some empirical support for this contention. In a
number of studies with different methodology, depressive affect has been associated
with a decrease in rCBF or metabolism in the left dorsolateral pre-frontal cortex [44,
45] and left frontal lesion, at least in the acute phase post-stroke [46]. On the other
hand, recent evidence indicates a right hemisphere dysfunction in anhedonia [47].

Coping strategies

903

Final rem arks and conclusions

In this study, across different statistical approaches, the authors have found a consistent negative relationship between approach-oriented coping and apathy, and a
positive association between avoidance coping and positive depressive symptoms.
These relationships have been described as two dimensions of adaptational behaviour in patients with acquired brain injury, an active vs. passive dimension and a
depression distress-avoidance dimension. Important elements of each dimension are
questionnaire based, self-reported coping strategies, but also neuropsychiatric symptoms: apathy and negative depressive symptoms associated with right hemisphere
and subcortical lesions in the active vs. passive dimension, and positive depressive
symptoms, associated with left hemisphere lesions in the distress-avoidance dimension.
These findings are interesting for at least two different reasons. In terms of
clinical implications, these findings should call for a careful distinction between
signs of apathy and signs of depression in patients with acquired brain injury, and
the relationships between coping patterns and neuropsychiatric symptoms confirm
the complex interplay between organic and psychological factors in these patients.
From a theoretical point of view, these findings confirm that a two dimensional
model of a psychological adaptational pattern an active vs. passive and an avoidance and distress dimension may be a fruitful model, even applied in a brain
injured population. The fact that these patients have acquired brain injuries, with
a variety of lesion locations, not only contributes to a larger variability in apathy
scores, but may also point towards differential cerebral mechanisms associated with
the two dimensions. Future research, both in non-brain injured and brain injured
samples, in the latter case with more refined methods of assessing lesion locations, is
needed, in order to clarify the scientific validity of the suggested model

Acknowledgem ents
This work was supported by the Research Council of Norway, the Mental Health
Program, grant # 111415/320. The authors thank Dr J. Berstad for assistance in
lesion classification, J. M. Krogstad for participation in clinical assessments, and Dr
Tore Gude for valuable comments to drafts.

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