Awareness of one's uniqueness as a person or "innate sense of self" results from the combined influences of experience, genetic endowment, defensive structure, and social reinforcers at any specified point in time. Changes in the environmental reinforcers play a major role in the regression observed in hospitalized patients without TBI (see Table 13–2). These same factors influence individuals with chronic medical illnesses such as TBI. Pressures to conform to an external set of demands in addition to the chameleon-like effect of TBI on personality further serve to confound the individual's sense of identity. This chameleon quality relates to the patient's adopting the behavioral characteristics of individuals in the immediate environment and underscores the need for placement in the least restrictive setting. A patient with brain injury may well act as one with a severe psychotic disorder when hospitalized on an acute admission unit or chronic care facility. Once returned to community-based supported living settings, dysfunctional styles improve. This issue has been the basis for numerous class action suits in Connecticut, Massachusetts, Maryland, and elsewhere to preclude commingling in state mental health facilities. When in the presence of more functional individuals, the patient shows a higher level of competence. Subtle deficits in executive function that accompany frontal lobe injuries in mild TBI may affect those individuals who rely on these skills for vocational or interpersonal success, such as lawyers, health care professionals, and entrepreneurs. Integrative deficits in visuospatial domains may undermine the confidence and skills of craftsmen whose jobs rely on these functions, such as welders, electricians, and artists. The chronic and enduring nature of these deficits requires a reworking of the internal representation of oneself, which may be hindered by the impairment in self-appraisal.