Unawareness of deficits in neuropsychological syndromes.

Damage to different regions of the brain can cause a variety of neuropsychological deficits, including specific disturbances of language, memory, perception and motor function. A significant number of brain-damaged patients are unaware of their deficits, even when they are profound and have debilitating effects on patients' performance. This article reviews clinical observations and experimental investigations concerning unawareness of deficits, considers methodological issues, and critically evaluates different interpretations of the phenomenon. An integrative theoretical framework is proposed to account for unawareness of deficits in diverse neuropsychological syndromes. Possible directions for future research are outlined.

[1]  D. N. Brooks,et al.  Methodological problems in assessing psychosocial recovery following severe head injury. , 1984, Journal of clinical neuropsychology.

[2]  L. Gustafson,et al.  Differential diagnosis of presenile dementia on clinical grounds , 1982, Acta psychiatrica Scandinavica.

[3]  G. Gainotti.  Emotional behavior and hemispheric side of the lesion. , 1972, Cortex; a journal devoted to the study of the nervous system and behavior.

[4]  P. Schilder.  PSYCHIC DISTURBANCES AFTER HEAD INJURIES , 1934 .

[5]  E. Warrington,et al.  AN EXPERIMENTAL ANALYSIS OF CONFABULATION IN A CASE OF KORSAKOFF'S SYNDROME USING A TACHISTOSCOPIC METHOD , 1960, Journal of neurology, neurosurgery, and psychiatry.

[6]  D. Surridge.  An Investigation into some Psychiatric Aspects of Multiple Sclerosis , 1969, British Journal of Psychiatry.

[7]  W. J. Hamilton,et al.  Anosognosia for hemiplegia , 1976, Neurology.

[8]  Jason W. Brown.  The Problem of Repetition: A Study of “Conduction” Aphasia and the “Isolation” Syndrome , 1975, Cortex.

[9]  T. Guthrie,et al.  A study of the syndromes of denial. , 1952, A.M.A. archives of neurology and psychiatry.

[10]  M. Myslobodsky,et al.  Cognitive Impairment in Patients with Tardive Dyskinesia , 1985, The Journal of nervous and mental disease.

[11]  E. Weinstein,et al.  Personality factors in denial of illness. , 1953, A.M.A. archives of neurology and psychiatry.

[12]  M. Cole,et al.  Anosognosia—Studies using regional intravenous anesthesia☆ , 1968 .

[13]  S. Cobb.  Amnesia for the left limbs developing into anosognosia; report of a case. , 1947, Bulletin of the Los Angeles Neurological Society.

[14]  D. Lindsley,et al.  After-Effects of Brain Injuries in War , 1943, Journal of The Royal Naval Medical Service.

[15]  M. Irving,et al.  SEVERE HEAD INJURIES: A Six-year Follow-up , 1967 .

[16]  L R Squire,et al.  Memory and metamemory: a study of the feeling-of-knowing phenomenon in amnesic patients. , 1986, Journal of experimental psychology. Learning, memory, and cognition.

[17]  T. Landis,et al.  Transient global amnesia: neuropsychological dysfunction during attack and recovery in two "pure" cases. , 1984, Journal of neurology, neurosurgery, and psychiatry.

[18]  K M Heilman,et al.  Hypometria with hemispatial and limb motor neglect. , 1986, Brain : a journal of neurology.

[19]  A. R. Lurii︠a︡,et al.  The neuropsychology of memory , 1977 .

[20]  C. Polkey,et al.  Self-Report of Memory Skills After Temporal Lobectomy: The Effect of Clinical Variables , 1980, Cortex.

[21]  D. Schacter,et al.  Acquisition of domain-specific knowledge in organic amnesia: Training for computer-related work , 1987, Neuropsychologia.

[22]  N. Geschwind,et al.  Acute confusional states with right middle cerebral artery infarctions. , 1976, Journal of neurology, neurosurgery, and psychiatry.

[23]  G. S. Ross,et al.  Transient global amnesia triggered by mild head trauma. , 1986, Brain : a journal of neurology.

[24]  L. Squire.  Comparisons between forms of amnesia: some deficits are unique to Korsakoff's syndrome. , 1982, Journal of experimental psychology. Learning, memory, and cognition.

[25]  P. Koehler,et al.  Aware or non-aware On the significance of awareness for the localization of the lesion responsible for homonymous hemianopia , 1986, Journal of the Neurological Sciences.

[26]  J. Vilkki.  Amnesic Syndromes After Surgery of Anterior Communicating Artery Aneurysms , 1985, Cortex.

[27]  W. Nauta.  The problem of the frontal lobe: a reinterpretation. , 1971, Journal of psychiatric research.

[28]  A. J. Welman.  Right-sided unilateral visual spatial agnosia, asomatognosia and anosognosia with left hemisphere lesions. , 1969, Brain : a journal of neurology.

[29]  R. C. Marshall,et al.  Self-monitoring behavior in a case of severe auditory agnosia with aphasia , 1985, Brain and Language.

[30]  M. Myslobodsky,et al.  Parkinsonian symptoms in tardive dyskinesia. A prevalence study. , 1986, South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde.

[31]  D. Stuss,et al.  The Frontal Lobes , 1986 .

[32]  J. Kihlstrom,et al.  Mental Representations of the Self , 1984 .

[33]  F. A. Whitlock.  Some observations on the meaning of confabulation. , 1981, The British journal of medical psychology.

[34]  E. Weinstein,et al.  CONCEPTS OF ANOSOGNOSIA , 1962 .

[35]  O. L. Zangwill,et al.  RECOVERY OF SPATIAL ORIENTATION IN THE POST-TRAUMATIC CONFUSIONAL STATE , 1944 .

[36]  T. Najenson,et al.  Re-evaluation of prognostic factors in rehabilitation after severe head injury. Assessment thirty months after trauma. , 1977, Scandinavian journal of rehabilitation medicine.

[37]  Y. Ben-Yishay,et al.  Neuropsychologic Rehabilitation: Quest for a Holistic Approach , 1985 .

[38]  D. Williams,et al.  Visual function in patients with homonymous hemianopia. III. The completion phenomenon; insight and attitude to the defect; and visual functional efficiency. , 1963, Brain : a journal of neurology.

[39]  B. Milner,et al.  Further analysis of the hippocampal amnesic syndrome: 14-year follow-up study of H.M.☆ , 1968 .

[40]  O. Zangwill.  4 – The Amnesic Syndrome , 1977 .

[41]  John G. Borkowski,et al.  Searching for Metamemory-Memory Connections: A Developmental Study , 1980 .

[42]  S. Breznitz.  The Denial of stress , 1983 .

[43]  Brockman Nw,et al.  Denial of own blindness (Anton's syndrome); report of two cases, one with autopsy. , 1946 .

[44]  P. Sandifer.  Anosognosia and disorders of body scheme. , 1946, Brain : a journal of neurology.

[45]  M. Alexander,et al.  Mechanisms of confabulation , 1981, Neurology.

[46]  U. Danielsen,et al.  Denial and neglect of hemiparesis in right‐sided apoplectic lesions , 1981, Acta neurologica Scandinavica.

[47]  E. Warrington.  The completion of visual forms across hemianopic field defects , 1962, Journal of neurology, neurosurgery, and psychiatry.

[48]  Michael P. Alexander,et al.  Clinical Neuropsychology, 2nd Ed. , 1987, Neurology.

[49]  Ann L. Brown.  Knowing When, Where, and How to Remember: A Problem of Metacognition. Technical Report No. 47. , 1977 .

[50]  Douglas J. Herrmann,et al.  Know thy memory: The use of questionnaires to assess and study memory. , 1982 .

[51]  T. O. Nelson,et al.  A NEW TECHNIQUE FOR INVESTIGATING THE FEELING OF KNOWING , 1980 .

[52]  A. Tyerman,et al.  Changes in self‐concept following severe head injury , 1984, International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation.

[53]  M. Myslobodsky.  Anosognosia in tardive dyskinesia: "tardive dysmentia" or "tardive dementia"? , 1986, Schizophrenia bulletin.

[54]  Feinberg Jf.  The Wernicke-Korsakoff syndrome. , 1980 .

[55]  N. Geschwind,et al.  Disorders of higher cortical functions in acute confusional states. , 1972, Cortex; a journal devoted to the study of the nervous system and behavior.

[56]  D Galin,et al.  Implications for psychiatry of left and right cerebral specialization. A neurophysiological context for unconscious processes. , 1974, Archives of general psychiatry.

[57]  C. Tompkins,et al.  Verbal self-correction behaviors of fluent and nonfluent aphasic subjects , 1982, Brain and Language.

[58]  D N Brooks,et al.  The short-term outcome of severe blunt head injury as reported by relatives of the injured persons. , 1981, Journal of neurology, neurosurgery, and psychiatry.

[59]  M Freedman,et al.  Amnesia after anterior communicating artery aneurysm rupture , 1984, Neurology.

[60]  F. Redlich,et al.  DENIAL OF BLINDNESS BY PATIENTS WITH CEREBRAL DISEASE , 1945 .

[61]  W. R. Brain.  VISUAL DISORIENTATION WITH SPECIAL REFERENCE TO LESIONS OF THE RIGHT CEREBRAL HEMISPHERE , 1941 .

[62]  M. Nathanson,et al.  Denial of illness; its occurrence in one hundred consecutive cases of hemiplegia. , 1952, A.M.A. archives of neurology and psychiatry.

[63]  S. Cobb.  Borderlands of Psychiatry , 1944 .

[64]  J. Pernier,et al.  Anosognosia with hemiplegia: auditory evoked potential studies. , 1982, Advances in neurology.

[65]  N. Roth.  UNUSUAL TYPES OF ANOSOGNOSIA AND THEIR RELATION TO THE BODY IMAGE , 1944 .

[66]  M. Romano.  Family response to traumatic head injury. , 1974, Scandinavian journal of rehabilitation medicine.

[67]  D. Johnson,et al.  Social adjustment and interaction after severe head injury. , 1985, The British journal of clinical psychology.

[68]  E. Zigler,et al.  Denial and self-image in stroke, lung cancer, and heart disease patients. , 1975, Journal of consulting and clinical psychology.

[69]  R. Trieschmann.  Spinal Cord Injuries: Psychological, Social and Vocational Adjustment , 1980 .

[70]  E. Weinstein,et al.  Meaning in jargon aphasia. , 1966, Transactions of the American Neurological Association.

[71]  M. Harrower,et al.  Psychological studies on patients with multiple sclerosis. , 1951, A.M.A. archives of neurology and psychiatry.

[72]  D. Jacome.  Case Report: Subcortical Prosopagnosia and Anosognosia , 1986 .

[73]  D. Denny-Brown,et al.  Amorphosynthesis from left parietal lesion. , 1954, A.M.A. archives of neurology and psychiatry.

[74]  J. Cutting.  Study of anosognosia. , 1978, Journal of neurology, neurosurgery, and psychiatry.

[75]  N. Geschwind.  Disconnexion syndromes in animals and man. I. , 1965, Brain : a journal of neurology.

[76]  K. Heilman,et al.  Hypoarousal in patients with the neglect syndrome and emotional indifference , 1978, Neurology.

[77]  W. LaBaw.  Denial inside out: subjective experience with anosognosia in closed head injury. , 1969, Psychiatry.

[78]  J. Fletcher,et al.  Scintigraphic Appearance of Anton's Syndrome , 1981 .

[79]  D. Schacter.  Memory, amnesia, and frontal lobe dysfunction , 1987, Psychobiology.

[80]  R. Pratt,et al.  DISORDERS OF PERCEPTION AND PERFORMANCE IN A CASE OF RIGHT-SIDÈD CEREBRAL THROMBOSIS , 1952, Journal of neurology, neurosurgery, and psychiatry.

[81]  T. Alajouanine,et al.  VERBAL REALIZATION IN APHASIA , 1956 .

[82]  D. Schacter,et al.  Memory Remediation: Restoration, Alleviation, and the Acquisition of Domain-Specific Knowledge , 1986 .

[83]  G. Talland.  CONFABULATION IN THE WERNICKE-KORSAKOFF SYNDROME , 1961, The Journal of nervous and mental disease.

[84]  Costanza Papagno,et al.  Unawareness of disease following lesions of the right hemisphere: Anosognosia for hemiplegia and anosognosia for hemianopia , 1986, Neuropsychologia.

[85]  Peter La Cour,et al.  Rivermead Behavioural Memory Test , 1990 .

[86]  B. Ford.  Head injuries--what happens to survivors. , 1976, The Medical journal of Australia.

[87]  L. Jarho.  Korsakoff-like amnesic syndrome in penetrating brain injury. A study of Finnish war veterans. , 1973, Acta neurologica Scandinavica. Supplementum.

[88]  Daniel L. Schacter,et al.  Memory Function After Closed Head Injury: A Review of the Quantitative Research , 1977, Cortex.

[89]  G. Gainotti.  Reactions “catastrophiques” et manifestations d'indifference au cours des atteintes cerebrales , 1969 .

[90]  M. Irving,et al.  SEVERE HEAD INJURIES , 1967 .

[91]  E. Heidbreder,et al.  Review of Aftereffects of brain injuries in war. , 1943 .

[92]  E. Weinstein,et al.  ANOSOGNOSIA AND APHASIA. , 1964, Archives of neurology.

[93]  C. Fisher.  Transient global amnesia. Precipitating activities and other observations. , 1982, Archives of neurology.

[94]  J. Hart,et al.  Memory and the feeling-of-knowing experience. , 1965, Journal of educational psychology.

[95]  K. Patterson.  Phonemic Dyslexia: Errors of Meaning and the Meaning of Errors , 1978, The Quarterly journal of experimental psychology.

[96]  B. Reisberg,et al.  Clinical Symptoms Accompanying Progressive Cognitive Decline and Alzheimer’s Disease , 1985 .

[97]  I. Bodis-Wollner,et al.  Absence of somatosensory evoked potentials in patients with anosognosia , 1977, Neurology.

[98]  J. Wepman.  The relationship between self-correction and recovery from aphasia. , 1958, The Journal of speech and hearing disorders.

[99]  J. Gerstmann.  PROBLEM OF IMPERCEPTION OF DISEASE AND OF IMPAIRED BODY TERRITORIES WITH ORGANIC LESIONS RELATION TO BODY SCHEME AND ITS DISORDERS , 1942 .

[100]  M. Lezak.  Living with the characterologically altered brain injured patient. , 1978, The Journal of clinical psychiatry.

[101]  G. Landi,et al.  Transient global amnesia due to left temporal haemorrhage , 1982, Journal of neurology, neurosurgery, and psychiatry.

[102]  Weinstein Ea,et al.  Behavioral disorders associated with hemi-inattention. , 1977 .

[103]  I. V. Thomsen.  The patient with severe head injury and his family. A follow-up study of 50 patients. , 1974, Scandinavian journal of rehabilitation medicine.

[104]  Ruth Garner,et al.  Monitoring of Understanding: An Investigation of Good and Poor Readers' Awareness of Induced Miscomprehension of Text , 1980 .

[105]  D. Neary,et al.  Neuropsychological syndromes in presenile dementia due to cerebral atrophy. , 1986, Journal of neurology, neurosurgery, and psychiatry.

[106]  S. Dimond.  Brain circuits for consciousness. , 1976, Brain, behavior and evolution.

[107]  A. Gruen,et al.  Motivational and structural factors in the denial of hemiplegia. , 1960, Transactions of the American Neurological Association.

[108]  Robert L. Rodnitzky,et al.  Neurobehavioral Consequences of Closed Head Injury , 1982 .

[109]  W. Hirst,et al.  The amnesic syndrome: descriptions and explanations. , 1982, Psychological bulletin.

[110]  B. Reisberg,et al.  An overview of current concepts of Alzheimer's disease. , 1982, The American journal of psychiatry.

[111]  V. Häkkinen,et al.  EFFECT OF CLONAZEPAM (Ro 5‐4023) ON INTERICTAL EEG ABNORMALITIES , 1973, Acta neurologica Scandinavica. Supplementum.

[112]  J. M. Schneck.  Alice James, Dr. Charles Lloyd Tuckey, and Hypnotherapy , 1982 .

[113]  J. Frederiks.  Disorders of the body schema , 1969 .

[114]  D. Stuss,et al.  An extraordinary form of confabulation , 1978, Neurology.

[115]  D L Schacter,et al.  Preserved learning in amnesic patients: perspectives from research on direct priming. , 1986, Journal of clinical and experimental neuropsychology.

[116]  Horton Pc.  Personality disorder and parietal lobe dysfunction. , 1976 .

[117]  Anne van Kleeck,et al.  The Emergence of Linguistic Awareness: A Cognitive Framework. , 1982 .

[118]  K. Cicerone,et al.  Cognitive Assessment in the Neuropsychological Rehabilitation of Head-Injured Adults , 1986 .

[119]  D. Denny-Brown,et al.  The significance of perceptual rivalry resulting from parietal lesion. , 1952, Brain : a journal of neurology.

[120]  M. Roth.  Disorders of the body image caused by lesions of the right parietal lobe. , 1949, Brain : a journal of neurology.

[121]  G. Donnan,et al.  Transient global amnesia—a hippocampal phenomenon? , 1980, Journal of neurology, neurosurgery, and psychiatry.

[122]  B. Volpe,et al.  Amnesia following the rupture and repair of an anterior communicating artery aneurysm. , 1983, Journal of neurology, neurosurgery, and psychiatry.

[123]  Daniel B Hier,et al.  Behavioral abnormalities after right hemisphere stroke , 1983, Neurology.

[124]  D. Bear.  Hemispheric specialization and the neurology of emotion. , 1983, Archives of neurology.

[125]  Morley Jb,et al.  Cortical blindness with anosognosia subsequent simultaneous agnosia and persistent gross recent memory defect. , 1974 .

[126]  S. Yussen,et al.  The Development of Metacognitive Awareness in Memory, Communication, and Attention. , 1979 .

[127]  J. Spillane.  DISTURBANCES OF THE BODY SCHEME ANOSOGNOSIA AND FINGER AGNOSIA , 1942 .

[128]  T. Jensen,et al.  Transient global amnesia – its clinical and pathophysiological basis and prognosis , 1981, Acta neurologica Scandinavica.

[129]  E. Weinstein,et al.  The syndrome of anosognosia. , 1950, A.M.A. archives of neurology and psychiatry.

[130]  J. Byer,et al.  Musical performance during transient global amnesia , 1980, Neurology.

[131]  U. Danielsen,et al.  Visual neglect in right‐sided apoplectic lesions , 1981, Acta neurologica Scandinavica.

[132]  K. Goldstein,et al.  Analysis of a case of figural blindness. , 1938 .

[133]  E. Clark.  Awareness of Language: Some Evidence from what Children Say and Do , 1978 .

[134]  A. Sai-Halász.  Psychic alterations in disseminated sclerosis; a general, statistical and Rorschach-test study on 200 patients. , 1956, Monatsschrift fur Psychiatrie und Neurologie.

[135]  E. Weinstein,et al.  Denial of illness : symbolic and physiological aspects , 1955 .

[136]  F. Weber.  AGNOSIA OF HEMIPLEGIA AND OF BLINDNESS AFTER CEREBRAL EMBOLISM , 1942 .

[137]  J. H. Evans,et al.  Transient loss of memory, an organic mental syndrome. , 1966, Brain : a journal of neurology.

[138]  H. Miller,et al.  THE LONG-TERM PROGNOSIS OF SEVERE HEAD INJURY. , 1965, Lancet.

[139]  P. Schilder.  The Image and Appearance of the Human Body: Studies in the Constructive Energies of the Psyche , 1936 .

[140]  F. Rose,et al.  Persistent memory defect following encephalitis. , 1960, Brain : a journal of neurology.

[141]  L. Squire,et al.  A psychosocial study of chronic, circumscribed amnesia. , 1981, The Journal of nervous and mental disease.

[142]  P. Bergman,et al.  Cerebral blindness; an analysis of twelve cases, with especial reference to the electroencephalogram and patterns of recovery. , 1957, A.M.A. archives of neurology and psychiatry.

[143]  L. Ross,et al.  Persistence of inaccurate beliefs about the self: perseverance effects in the classroom. , 1986, Journal of personality and social psychology.

[144]  M. B. Bender,et al.  Unilateral spatial agnosia (inattention) in patients with cerebral lesions. , 1956, Brain : a journal of neurology.

[145]  C. Fisher.  Transient global amnesia , 1958 .

[146]  D. Hamburg,et al.  Adaptive problems and mechanisms in severely burned patients. , 1953, Psychiatry.

[147]  K. Heilman,et al.  Auditory neglect in man. , 1972, Archives of neurology.

[148]  B. Swartz,et al.  Anton's syndrome accompanying withdrawal hallucinosis in a blind alcoholic , 1984, Neurology.

[149]  C. Rupp,et al.  OBSERVATIONS ON CONFABULATION , 1938 .

[150]  C. W. Olsen,et al.  ANOSOGNOSIA AND AUTOTOPAGNOSIA , 1941 .

[151]  F. Wood,et al.  Persistent Retrograde Memory Deficit After Transient Global Amnesia , 1980, Cortex.

[152]  Daniel B Hier,et al.  Recovery of behavioral abnormalities after right hemisphere stroke , 1983, Neurology.

[153]  D. Schacter.  Feeling of knowing in episodic memory. , 1983 .

[154]  R. E. Hemphill,et al.  Contribution to the dressing disability as a focal sign and to the imperception phenomena. , 1948, The Journal of mental science.

[155]  M. Critchley.  The parietal lobes , 1966 .

[156]  E. Stengel,et al.  Unawareness of physical disability (anosognosia). , 1946, The Journal of mental science.

[157]  L. Squire.  Mechanisms of memory. , 1986, Lancet.

[158]  L. Cermak.  Human memory and amnesia , 1982 .

[159]  Object Reversals After Parietal Lobe Infarction - A Case Report , 1985, Cortex.

[160]  A. Weisman,et al.  DENIAL AS A FACTOR IN PATIENTS WITH HEART DISEASE AND CANCER , 1969, Annals of the New York Academy of Sciences.

[161]  Jason W. Brown.  Aphasia, apraxia, and agnosia , 1972 .

[162]  D. Schacter,et al.  Access to consciousness: Dissociations between implicit and explicit knowledge , 1986 .

[163]  Alan Sunderland,et al.  Do Laboratory Tests Predict Everyday Memory? A Neuropsychological Study. , 1983 .

[164]  D. Fordyce,et al.  Changes in perspectives of disability among patients, staff, and relatives during rehabilitation of brain injury. , 1986 .

[165]  Jason W. Brown.  Mind, brain, and consciousness : the neuropsychology of cognition , 1977 .

[166]  G. Alexopoulos.  Lack of complaints in schizophrenics with tardive dyskinesia. , 1979, The Journal of nervous and mental disease.

[167]  M. Ullman.  Behavioral changes in patients following strokes , 1962 .

[168]  E. Bisiach,et al.  Remission of hemineglect and anosognosia during vestibular stimulation , 1987, Neuropsychologia.

[169]  B. Giordani,et al.  Disability caused by minor head injury. , 1981, Neurosurgery.

[170]  H. Gardner,et al.  A study of confabulation. , 1977, Archives of neurology.

[171]  Y. Lebrun.  Anosognosia in Aphasics , 1987, Cortex.