CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:1135–1139
Patients With Minimal Hepatic Encephalopathy Have Poor Insight Into
Their Driving Skills
JASMOHAN S. BAJAJ,* KIA SAEIAN,‡ MUHAMMAD HAFEEZULLAH,‡ RAYMOND G. HOFFMANN,§ and
THOMAS A. HAMMEKE㛳
*Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia; ‡Division of
Gastroenterology and Hepatology, §Department of Biostatistics, 㛳Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
See Mardini H et al and Bajaj JS et al in the
December 2008 issue of Gastroenterology.
See CME exam on page 1065.
Background & Aims: Minimal hepatic encephalopathy
(MHE) is associated with impaired driving skills. It is not
clear whether patients have insight into this. The Driving
Behavior Survey (DBS) is a validated self- or observer-
administered questionnaire. DBS consists of a total score
(maximum, 104) and an attention-related driving skills sec-
tion (maximum, 40). DBS was used to compare self-assess-
ment with observer-assessment of driving skills in cirrhotic
patients tested for MHE. Methods: Forty-seven nonalco-
holic cirrhotic patients and 40 controls underwent psycho-
metric tests, DBS, and driving simulation with navigation/
driving tasks. An adult familiar with the subject’s driving
completed the DBS independently. Simulator perfor-
mances, total DBS scores, and driving skill scores were
compared between/within groups (MHEⴙ, MHEⴚ, and
controls) with respect to self-assessment and observer
assessment. Results: Thirty-six patients were MHEⴙ and 11
were MHEⴚ. MHEⴙ had a significantly higher simulator
crash (MHEⴙ, 3; MHEⴚ, 1.2; controls, 1.7; P ⴝ .001) and
illegal turn rate (MHEⴙ, 1.2; MHEⴚ, 0.3; controls, 0.1; P ⴝ
.0001). Despite this worse performance, MHEⴙ patients
rated themselves similar to MHEⴚ patients and control
groups on total (P ⴝ .28) and driving skills scores (P ⴝ .19).
Observer assessment in MHEⴙ was significantly lower for
total (P ⴝ .0001) and driving skills (P ⴝ .0001) compared
with observer assessment for MHEⴚ patients and control
groups. MHEⴙ patients were rated significantly lower on
driving skills (34 vs 37; P ⴝ .02) and trended lower in the
total score (P ⴝ .08) by observers compared with self-ratings.
In contrast, MHEⴚ and control groups rated themselves sim-
ilar to their observers on driving skills and total DBS scores.
Conclusions: MHE patients have poor insight into their
driving skills. A part of the MHE patient’s clinical interview
should be to increase awareness of this driving impairment.
M inimal hepatic encephalopathy (MHE) is a significant
neurocognitive complication of cirrhosis.1,2 It is present
in up to 80% of patients tested, it is associated with a poor
quality of life, and it is associated with increased progression to
overt hepatic encephalopathy.3–5 Importantly, MHE also is as-
sociated with driving behavior impairment.6 – 8 Driving difficul-
ties in patients with MHE can stem from deficiencies in several
components, including impaired reaction times, psychomotor
slowing, and navigation skill disturbances.9,10 A recent study
showed a higher risk of traffic violations and motor vehicle
accidents in patients with MHE.11 Insight into or self-awareness
of driving impairment is essential for patients to seek interven-
tion. Because patients with MHE have no specific symptoms, it
is important that factors that could prevent adverse driving
outcomes such as traffic accidents be studied by the physician
and the validity of the patient’s self-report of driving adequacy
be examined in detail.1
The Driving Behavior Survey (DBS) is a 26-item scale that
has been validated by Barkley et al12 in children and adults with
attention deficit hyperactivity disorder (ADHD). This question-
naire was chosen because both MHE and ADHD patients strug-
gle with attention problems and also show driving impairment.
It has been studied in MHE and previously was called the
Driving Behavior Questionnaire.12 Each question is rated on a
scale of 1 to 4 (maximum score, 104). Items on the DBS inquire
about both driving skills that can be readily affected by impair-
ment in attention, vigilance, and safety judgments (10 items
collectively referred to here as driving skills; eg, “reacts quickly
and properly to brake lights when activated on vehicles ahead”)
as well as items that relate to long-standing driving habits (16
items) (eg, “refers to maps before driving through a new area or
city”). In addition to the total scores, this research investigated
the self-assessment and observer-assessment of driving skills.
Higher scores indicate better driving.
The hypothesis of the study was that patients with MHE
have impaired insight into their driving behavior. The aims
were first to determine whether patients with MHE, a group
already known to make more errors in driving, accurately char-
acterize their driving behavior when compared with measures of
their driving skills and ratings of their driving from observers,
and, second, to determine whether impaired insight in MHE is
identified best by items on the DBS that are thought to be most
affected by an encephalopathic state (driving skills assessment).
Methods
Consecutive nonalcoholic patients with cirrhosis who
were car drivers and were tested for MHE were included.13
Cirrhotic patients on psychoactive drugs (including psychiatric
and seizure medications, ADHD therapy, and interferon), those
Abbreviations used in this paper: ADHD, attention deficit hyperac-
tivity disorder; DBS, Driving Behavior Survey; MHE, minimal hepatic
encephalopathy.
© 2008 by the AGA Institute
1542-3565/08/$34.00
doi:10.1016/j.cgh.2008.05.025
1136 BAJAJ ET AL
who had consumed alcohol within the past 6 months, and
those on treatment for overt hepatic encephalopathy were ex-
cluded. Alcohol use history was corroborated by relatives and in
the medical chart using serum alcohol levels at several points
during the medical evaluation. Patients underwent a detailed
physical examination to exclude overt hepatic encephalopathy.
After this they underwent a psychometric battery consisting of
the number connection test-A, the number connection test-B,
block design test, and digit symbol test components of the
Wechsler’s adult intelligence scale-III.6,14 MHE was diagnosed if
any 2 of these tests were impaired 2 SDs beyond age- and
education-matched community controls.6 The inhibitory con-
trol test, a test of response inhibition, with 90% sensitivity and
specificity for the diagnosis of MHE, also was administered to
all subjects during the same sitting.15 A group of age- and
education-matched healthy community controls, who were re-
cruited through community advertisements, also underwent
the same testing. Written informed consent was obtained from
each subject. All subjects were paid for their participation.
The DBS then was administered to all subjects and they also
were asked to provide the contact information for an adult
familiar with their driving habits. This adult, who was blinded
to the patient’s MHE status, then was contacted in the subject’s
absence. After confirming that the observer was familiar with
the subject’s driving, the DBS was administered to them by
telephone interview to judge the research subject’s driving habits.
All participants (cirrhotic patients and controls) underwent
driving simulation using a STISIM simulator, which has been
studied in patients with MHE and consists of training, naviga-
tion, and driving tasks (Systems Technology Inc, Hawthorne,
CA; technology in the model BR1100, Beta Research, Inc, Los
Gatos, CA).13 The training session lasted for 15 minutes and
familiarized the subjects with the driving simulator. The navi-
gation task consisted of driving on a fixed path while consult-
ing a map on the simulator. Illegal turns, defined as turns away
from the marked path on the map, and collisions during this
task were the outcome. The driving task consisted of driving on
a path that ranged from hilly terrain to city driving under
optimum weather conditions. The number of collisions was the
end point for this portion of the study.13
The Institutional Review Board at the Medical College of
Wisconsin approved this protocol.
Statistical Analysis
Diagnosis of MHE was made based on predetermined
criteria in our population, which meant any 2 of the following
criteria6,15: number connection test-A, greater than 34 seconds;
number connection test-B, greater than 99 seconds; block de-
sign test, less than 31 raw score; or digit symbol test, less than
71 raw score.
Analysis. Cirrhotic patients were divided into those
with MHE (MHE⫹) and without MHE (MHE⫺), and were
compared with controls with respect to demographics, self-
assessment and observer assessment of DBS total and driving
skill components, and driving simulation outcomes.
Student t tests were used to compare continuous variables
across groups and paired t tests were used to compare self-
assessment and observer assessment of DBS total and driving
skills within groups. Differences between self-assessment and
observer assessment (obtained by subtracting the observer score
from the self-score of the total DBS and driving skills component
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 10
of the DBS) across MHE⫹, MHE⫺, and control groups were
calculated and compared using multiple comparisons adjusted
t tests on the differences after a one-way analysis of variance.
Results are expressed as mean ⫾ SD unless otherwise specified.
Results
Seventy-four cirrhotic patients and 74 controls were
approached; 6 patients with cirrhosis refused to participate. A
total of 68 cirrhotic patients and 74 controls underwent psy-
chometric testing, self-assessment of DBS, and driving simula-
tion. The observers, whose information was provided by the
subjects, could be contacted in only 47 cirrhotic patients and 40
controls, who then were included in the final study. Of the 21
cirrhotic patients whose observers could not be contacted, 14
were MHE⫹ and 7 were MHE⫺.
There were 29 cirrhotic patients with hepatitis C, 5 had both
hepatitis C and alcoholic liver disease (without alcohol intake
within 6 months documented through personal interviews and
through chart review), 5 with autoimmune hepatitis, 3 with
primary sclerosing cholangitis, 1 with primary biliary cirrhosis,
and 1 with cryptogenic cirrhosis. Based on the psychometric
tests, 36 cirrhotic patients had MHE and the remaining 11 were
MHE⫺.
There was no significant difference in Child status, serum
creatinine level, bilirubin level, and international normalized
ratio between groups (Table 1). Two MHE⫹ and 1 MHE⫺
patient were on the waiting list for transplant.
Observers. Most observers were spouses (MHE⫹,
61%; MHE⫺, 55%; and controls, 55%; P ⫽ .6), and the remain-
ing observers were close friends (MHE⫹, 17%; MHE⫺, 27%; and
controls, 23%; P ⫽ .2) or first-degree relatives (MHE⫹, 22%;
MHE⫺, 18%; and controls, 12%; P ⫽ .2) who were familiar with
the subject’s driving.
Minimal hepatic encephalopathyⴙ group, mini-
mal hepatic encephalopathy– group, and control group
comparison. There was no significant difference in the de-
mographic characteristics and driving history between the
groups. On the other hand, MHE⫹ patients had a significantly
worse psychometric performance and higher rate of collisions
(both in driving and navigation task) and illegal turns on the
driving simulator compared to controls and MHE⫺ patients
(Table 1).
Comparison between the minimal hepatic en-
cephalopathy–negative group and controls. There was no
significant difference between controls and the MHE⫺ group
with respect to demographics and psychometric test perfor-
mance. There was no significant difference in the number of
collisions (P ⫽ .1) and illegal turns (P ⫽ .3) on the simulator
between MHE⫺ patients and controls (Table 1).
Self-report of driving abilities (Driving Behavior
Survey). There was no significant difference between MHE⫹,
MHE⫺, and control groups in self-assessment of driving abil-
ities as reflected by total DBS scores or the driving skills scores
(Table 2).
Observer versus self-ratings of driving abilities.
Observers rated MHE⫹ patients significantly lower on the driv-
ing skills compared with the subjects’ self-evaluation. There was
a trend towards a lower observer versus self-report for the total
DBS score. In contrast, there was no significant difference
between self-assessment and observer assessment on the total
October 2008 POOR INSIGHT IN MHE 1137

Table 1. Demographic, Psychometric, and Driving Simulator Performance

MHE⫹ (n ⫽ 36) MHE⫺ (n ⫽ 11) Controls (n ⫽ 40) P value among groups

Age, y 55 ⫾ 5 57 ⫾ 4 53 ⫾ 5 .09
Sex, male/female 21/15 6/5 25/15 .9
Child class, A/B/C 32/4/0 9/2/0 — .6
Serum creatinine level, mg/dL 1.1 ⫾ 0.9 0.9 ⫾ 0.7 — .7
International normalized ratio 1.3 ⫾ 0.9 1.1 ⫾ 0.5 — .5
Serum bilirubin level 1.5 ⫾ 1.2 1.1 ⫾ 0.8 — .3
Driving experience, y 24 ⫾ 5 27 ⫾ 4 28 ⫾ 5 .5
NCT-A, s 32 ⫾ 8 26 ⫾ 5 22 ⫾ 6 .0001
NCT-B, s 107 ⫾ 36 73 ⫾ 32 56 ⫾ 21 .0001
DST, raw score 51 ⫾ 14 80 ⫾ 9 79 ⫾ 15 .0001
BDT, raw score 31 ⫾ 12 38 ⫾ 6 49 ⫾ 18 .0001
ICT lures 10 ⫾ 5 3⫾2 4⫾2 .0001
Simulator driving task collisions 3⫾2 1.2 ⫾ 0.9 1.7 ⫾ 0.7 .0001
Simulator navigation task collisions 0.6 ⫾ 1 0.0 ⫾ 0 0.06 ⫾ 0.3 .009
Simulator illegal turns 1.2 ⫾ 0.8 0.3 ⫾ 0.4 0.1 ⫾ 0.3 .0001

NOTE. No significant difference in age, sex, Child class, serum variables of Model for End-stage Liver Disease (MELD) score, and driving
experience was noted between groups. A significantly impaired performance on the driving simulator and ICT was observed in the MHE⫹ group.
Serum values for controls were not drawn.
NCT-A, number connection test-A; NCT-B, number connection test-B; DST, digit symbol test; BDT, block design test; ICT, inhibitory control test.

DBS or the driving skills in the MHE⫺ or the control groups
(Table 2).
Comparison of observer Driving Behavior Survey
assessment between groups. MHE⫹ patients were as-
sessed significantly lower on their total DBS and driving skills
component by their raters compared with the ratings in the
MHE⫺ and control groups (Table 2).
Comparison of differences in self-scores and ob-
server scores between groups. There was a significantly
greater difference between self-ratings and observer ratings
of the total DBS score in MHE⫹ patients (3.5 ⫾ 1.6 [SE])
compared with MHE⫺ patients (⫺2.5 ⫾ 2 [SE]) and controls
(⫺2.5 ⫾ 1 [SE]; P ⫽ .03). Similarly, the difference between
self-assessment and observer assessment of the driving skills
component was higher in MHE⫹ patients (2 ⫾ 0.9 [SE]) com-
pared with MHE⫺ patients (⫺0.2 ⫾ 0.7 [SE]) and controls
(⫺0.3 ⫾ 0.8 [SE]; P ⫽ .04) (Figure 1).
Discussion
The current study shows that patients with MHE rate
themselves equivalent to controls and cirrhotic patients with-
out MHE despite having a significantly worse driving perfor-
mance. Also, observers rate MHE⫹ patients as poorer drivers
compared with MHE⫺ patients or controls. These findings
indicate that MHE⫹ patients have poor insight into their
driving deficiencies.
These results show that this poor insight is evident despite a
significantly higher collision and illegal turn rate on the driving
simulator. MHE⫹ patients rated themselves equivalent to con-
trols and MHE⫺ patients on the total DBS score as well as
driving skill assessment. Observers familiar with their driving
skills rated MHE⫹ patients significantly lower than the pa-
tients’ self-rating. Moreover, observer assessment of total DBS
and driving skills component in MHE⫹ patients was signifi-
cantly lower compared with the observer assessment of MHE⫺
and control groups. The difference between self-assessment and
observer assessment also was significantly higher in the MHE⫹
group compared with the MHE⫺ and control groups.
MHE has been associated with difficulty in driving and a
high risk of traffic accidents and violations.9 –11 Proposed rea-
sons for this driving difficulty include impaired reaction times,
decreased visuomotor coordination, and navigation prob-
lems.9,10,13 This multidimensional driving impairment requires
continued investigation and definition because traffic accidents

Table 2. DBS Comparison Within and Between Groups

P value of comparison
between self-assessment
and observer assessment
MHE⫹ MHE⫺ Controls P value
(n ⫽ 36) (n ⫽ 11) (n ⫽ 40) among groups MHE⫹ MHE⫺ Controls

Total DBS: self-assessment (maximum, 104) 95 ⫾ 7 96 ⫾ 6 95 ⫾ 7 .28 .08 .4 .5

Total DBS: observer assessment (maximum, 104) 89 ⫾ 9 98 ⫾ 4 97 ⫾ 7 .0001
Driving skills: self-assessment (maximum, 40) 37 ⫾ 3 38 ⫾ 1 37 ⫾ 1 .19 .02 .8 .9
Driving skills: observer assessment (maximum, 40) 34 ⫾ 5 38 ⫾ 2 38 ⫾ 2 .0001

NOTE. A significantly lower observer assessment of driving skills in MHE⫹ group compared with self-assessment was noted. Observer
assessment of total DBS and driving skills was significantly lower in the MHE⫹ group compared with the observer assessment in MHE⫺ and
control groups.
1138 BAJAJ ET AL
Figure 1. Difference between MHE⫹, MHE⫺, and controls’ self-as-
sessment and observer assessment of total DBS and driving skills
component showed that there was a significantly higher difference be-
tween the self-ratings and observer ratings in MHE⫹ compared with
MHE⫺ patients and controls.
are a leading cause of morbidity and mortality in the United
States.16
Because patients with MHE have no symptoms, evaluation
of self-awareness in MHE patients can be challenging in this
group.1,2,17,18 However, the manifestations of poor driving skills
are evident from the higher number of traffic accidents and
violations that MHE⫹ patients experienced in the simulator
and in real life.11,13 Therefore, the importance of specifically
inquiring about the driving history in patients with cirrhosis
would help create awareness in the patient and hopefully help
the development of insight into this issue. In addition, educa-
tion of patients and relatives regarding the driving impairments
in MHE also would be helpful in raising self-awareness about
driving practices.
Recent literature has highlighted the negative impact of
cirrhosis on survival after trauma and traffic accidents.19 –21 This
further accentuates the risk that MHE⫹ drivers face while
driving. Therefore, it follows that an objective evaluation, such
as a driving history and corroboration from relatives in patients
with cirrhosis, would identify individuals at a particularly high
risk of poor driving outcomes. Corroboration from relatives has
been used to confirm alcohol use in patients with cirrhosis.22
This should be extended to driving behavior as well because this
study shows that adult observers are acutely observant of driv-
ing impairments.
Similar to MHE⫹ patients, patients with ADHD suffer from
attention deficits.23 ADHD patients also have several driving
impairments and difficulties with psychometric function,
which is why the DBS, which has been studied in ADHD, was
chosen for this study.12,23,24 Parents assessing their children
with ADHD using the DBS rated the children’s driving skills
significantly lower than those who did not have ADHD.12 Pa-
tients with ADHD are decidedly younger than most patients
with cirrhosis and are actively seeking medical attention for
problems related to inattentiveness. In addition, the age range
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 6, No. 10
of most ADHD patients is associated with a high risk of traffic
accidents and violations even without the compounding dele-
terious effect of ADHD.23 On the other hand, MHE⫹ patients
are older than ADHD patients. The patients in the current
study population are in the age range of the safest age group of
any population with respect to traffic violations and accidents.
Thus, driving assessment differences are likely to be more subtle
than those expected in ADHD. Parents assessing children for
whom they are seeking treatment are also likely to rate them
differently compared with assessment of adult raters of a pa-
tient (with MHE) who has not sought medical attention for
that condition. Vested interests, such as a spouse protecting
their partners’ ability to drive by falsely rating them higher, also
would be expected to play a key role in that assessment. Because
subjects were free to provide the contact information of an
observer of their choice, it may be possible that these vested
interests would dictate the choice of the observer, that is,
subjects would probably name an observer who would be likely
to give a favorable assessment of their driving. Despite these
complicating factors, observers rated MHE⫹ patients much
lower with respect to their driving skills compared with their
self-assessment. There was also a trend towards lower total DBS
scores in observers compared with self-assessment in the
MHE⫹ group. In sharp contrast, there was no significant dif-
ference in the driving skills rating or total DBS score between
self and observer assessment in the group without MHE and
controls.
Insight into a disease state is one of the most significant
forces that can spur patients to seek health care.25 Absence of
insight or poor insight can hinder acknowledgment of the
disease process and interfere with potential recognition and
treatment. The trans-theoretical model of health behavior
change also suggests that patients with MHE and driving dif-
ficulties may be in the pre-contemplation stage of change.25
This stage is characterized by an unwillingness to recognize a
problem either because the patient is unaware of the problem
or believes that they will be unable to change their behavior.25
Because of their lack of personal insight into their driving skills,
MHE patients are not aware of their driving impairment.
Anosognosia or attenuated awareness of sensory and cognitive
deficits has been noted in several diseases such as Alzheimer’s
disease, schizophrenia, and traumatic brain injury.26 –28 It has
been associated with a worse prognosis and dangerous behav-
iors in Alzheimer’s disease.26,29 One study showed that one third
of patients with Alzheimer’s disease who failed a driving test
still considered themselves “safe” drivers.30 Anosognosia in
overt hepatic encephalopathy is evident because relatives are
often the first to notice changes in behavior and bring them to
medical attention.31 In contrast, MHE patients by definition
have no specific symptoms.1 We suggest that, similar to their
lack of awareness of the driving deficits, the lack of awareness of
attention deficits and psychomotor slowing represents a core
symptom of MHE patients and underlies their diminished
appreciation of driving deficits.
In summary, patients with MHE have poor insight into their
driving skills. Because of this, an objective driving history,
corroboration with relatives, and education of patients, rela-
tives, and caregivers regarding driving practices should be com-
pleted as part of the clinical interview. This would increase the
patient’s self-awareness of the driving impairment and increase
the implementation of appropriate therapy in MHE patients.
October 2008
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Address requests for reprints to: Jasmohan S. Bajaj, MD, MS, Division of
Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W
Wisconsin Avenue, Milwaukee, Wisconsin 53226. e-mail: jasmohan.
bajaj@va.gov.
The authors disclose no financial conflicts of interest.