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03-06-2015 | Uitgave 11/2015

Quality of Life Research 11/2015

A new perspective on proxy report: Investigating implicit processes of understanding through patient–proxy congruence

Quality of Life Research > Uitgave 11/2015
Carolyn E. Schwartz, Armon Ayandeh, Jonathan D. Rodgers, Paul Duberstein, Bianca Weinstock-Guttman, Ralph H. B. Benedict
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The online version of this article (doi:10.​1007/​s11136-015-1017-4) contains supplementary material, which is available to authorized users.
All our knowledge begins with the senses, proceeds then to the understanding, and ends with reason.
Immanuel Kant



Utilizing proxy report is a common solution to gathering quality-of-life information from people who are not capable of reliably answering questionnaires, such as people with dementia. Proxy report could, however, also provide information about patients’ implicit processes of understanding, which we define as automatic, schema-driven cognitive processes that allow one to have a better understanding of oneself and of one’s body, make oneself known and knowable to members of the social network, and allow one to react proactively in response to cues. We investigated whether implicit processes of understanding explain some of the association between reserve and healthy lifestyle behaviors.


We operationalized three implicit processes of understanding: (a) psychosocial understanding; (b) insight into physical disability; and (c) somatic awareness. This secondary analysis involved a cohort of multiple sclerosis patients and their caregiver informants (n = 118 pairs). Measures included a neurologist-administered Expanded Disability Status Scale, patient- and informant-completed survey measures, and a heartbeat perception test (interoception). Patient–other congruence assessed implicit processes of understanding: psychosocial understanding (neurocognitive and personality); physical-disability insight; and somatic awareness (interoception).


Effect sizes (ES) for the inter-correlations between the three implicit processes were small. Psychosocial understanding was associated with higher past reserve-building activities (small ES). Psychosocial understanding explained variance in healthy lifestyle behaviors over and above the variance explained by current reserve-building activities (∆R 2 = 0.04; model R Adjusted 2  = 0.18).


Proxy versus patient report can provide information about underlying interpretational processes related to insight. These processes are distinct from reserve, predict health outcomes, and can inform lifestyle-changing interventions.

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