J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

Journal ofNeurology, Neurosurgery, andPsychiatry, 1978, 41, 548-555

Study of anosognosia

JOHN CUTTING From the Institute of Psychiatry and King's College Hospital, London

SUMMARY Anosognosia (denial of weakness) and "anosognosic phenomena" (other abnormal attitudes to a weak limb) were studied in 100 acute hemiplegics. Both conditions were associated with lesions of either hemisphere. Apathy, visual field defect, and impaired picture identifica- tion were particularly prominent in anosognosia. A failure to integrate information from one side of the body was regarded as fundamental to the condition; explanations in terms of "unilateral neglect" and "agnosia" are discussed.

Babinski introduced the word "anosognosia" in have attributed to right hemisphere damage a pre- 1914 as a description of patients who ignored their eminent role in its development (Bogen, 1969; hemiplegia. In current usage the term embraces Galin, 1974). It is true that anosognosia for a right Protected by copyright. a variety of abnormal attitudes. Chief among these hemiplegia has only rarely been recorded. Exclud- is an explicit verbal denial that the limb is weak. ing left handed patients and those with bilateral Some patients, although admitting to their dis- lesions, only four case reports remain (Von Hagen ability on direct questioning, minimise its extent, and Ives, 1937; Nathanson et al., 1952; Weinstein often in a jocular fashion (anosodiaphoria, and Kahn, 1955; Welman, 1969). However, the Babinski, 1914). Yet others experience the limb presence of aphasia in patients with left hemis- as strange or not belonging to them, or even phere lesions complicates the issue. Gtoss and attribute ownership to another person (somato- Kaltenbiick (1955) found that 91% of right hemi- paraphrenia, Gerstmann, 1942). Some express plegics with a field defect and sensory loss, hatred of the limb (miEoplegia, Critchley, 1962), features which had predicted anosognosia in their some give it a nickname (personification, Juba, counterparts with a left hemiplegia, were totally 1949), and some overestimate the strength of an aphasic in the first week after onset. They con- unaffected limb (anosognosic overestimation, cluded, therefore, that right hemiplegics at risk for Anastasopoulos, 1961). A false belief that the limb developing anosognosia were the very patients in is moving (kinaesthetic hallucinations, Walden- whom aphasia precluded its determination. In the strom, 1939) or that a separate limb has appeared light of these difficulties, the association between http://jnnp.bmj.com/ in another part of the body (phantom super- anosognosia and right hemisphere damage may be numerary limb, Ehrenwald, 1930) may occur. more apparent than real. Although these phenomena are generally regarded The independence of anosognosia from a general as related in some way, there is no agreement on cognitive impairment is suggested by individual an overall classification. Frederiks' (1969) division reports of patients with intact orientation (Walden- into "explicit denial" and "anosognosic be- strom, 1939; Gilliatt and Pratt, 1952). However, havioural disturbances" (incorporating all the three of the only four series of patients (Nathanson other phenomena) is attractive, and will be used et al., 1952; Weinstein and Kahn, 1955; Ullman, on September 26, 2021 by guest. in this report. For the sake of convenience, these 1962) recorded disorientation in every instance of will be referred to respectively as "anosognosia" anosognosia, and the authors of the fourth series and "anosognosic phenomena." (Gross and Kaltenback, 1955) maintained that al- The association of anosognosia with a left hemi- though 18% were correctly oriented, they suffered plegia has been found so often that some authors from a milder degree of "confusion," which they termed "lack of critical awareness of Address for reprint requests: Dr J. Cutting, Institute of Psychiatry, surroundings." de Crespigny Park, Denmark Hill, London SE5 8AF. Resolution of these central issues might lead in Accepted 30 January 1978 part to a clearer appreciation of the nature of 548 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

Study of anosognosia 549 anosognosia. At present, theories range from analyses because it only mirrored the absolute psychodynamic interpretations of motivation rates of loss. (Weinstein and Kahn, 1955) to detailed neuro- physiological explanations of the role of central HIGHER MENTAL FUNCT[ION sensory pathways (Frederiks, 1969; Waldenstrom, Six aspects of higher mental function were sys- 1939). Other factors, in particular "neglect," have tematically studied. Orientation, attention, and been less investigated, and the aim of the present memory were assessed by asking patients to orien- study was to examine the basis for the major tate themselves in time and place, to repeat digits, theoretical positions by correlating deficits in and to remember a name and address and details higher mental functions with the emergence of of their admission. Mood was observed and re- anosognosia and its phenomena in a consecutive corded as pathological (euphoric, apathetic, or series of patients with an acute hemiplegia. depressed) if it appeared inappropriate to the cir- cumstances. Personal neglect was regarded, at Patients and methods Critchley's (1953) suggestion, as a disinclination of the contralateral hand to cross the midline. In One hundred patients with an acute hemiplegia the presence of weakness it is difficult to separate were seen over a period of two years in a general personal neglect from an abnormal attitude to a hospital. Weekly visits were paid to all medical paralysis, and in left hemisphere lesions, from dis- wards, and the notes of all patients with a pro- turbances of body naming. Some indication of visional diagnosis of a cerebrovascular accident this, however, for patients with a left hemiplegia, were inspected. Cases were rejected if the hemi- was achieved by asking them to touch parts of the plegia was more than eight days old, if there was body on the left side (little finger, thumb, elbow, no recorded limb weakness, if any weakness had ear) with the right hand. Visuospatial neglect was Protected by copyright. totally recovered by the time the patient was seen estimated by inspecting their drawings of a face, by the author, or if the patient was unconscious a clock, and a map of England with six cities. The on the day of the visit. About 50 patients were simple neglect test of Albert (1973), which re- excluded in this way, and the remaining 100 were quires patients to score out lines on a piece of considered to be representative of acute hemi- paper, was also used; those with neglect omit lines plegics without prolonged unconsciousness or on one side. Visual perception was tested by pre- rapid resolution admitted to a general hospital. senting 20 pictures of moderately uncommon ob- No detailed analysis of the localisation within a jects-for example, speedometer, accordion-and hemisphere or of the pathology of the lesion was asking for a correct identification, name, or func- planned, but some comment on this is appropriate. tional description. The task was entirely visual and The exclusion of any patient whose weakness had performance was easily contrasted with the been present for longer than a week ensured that patients' abilities in the other language tests given. a cerebrovascular accident was likely. Investiga- The test was given to 30 controls (10 Korsakoff tions were incomplete at the time of the first visit, subjects, 10 alcoholics, and 10 patients with per-

but notes were inspected subsequently, and in four ipheral neuropathy), and as the lowest identifica- http://jnnp.bmj.com/ cases there was evidence that a tumour and not a tion score among these was 14 out of 20, any vascular lesion had been responsible. No patient score below this was suggestive of impaired visual with bilateral weakness was included, but three perception. The mean scores for any groups were had pyramidal tract signs on the side opposite to also calculated. that currently affected. This suggested that bi- lateral brain damage was present in 3%o. LANGUAGE Language was assessed for expressive deficits, re-

GENERAL EXAMINATION ceptive deficits (by asking questions of increasing on September 26, 2021 by guest. General features (age, sex, handedness, occurrence complexity requiring nonverbal answers, for of a previous paresis, and duration and side of example, point to where the illumination of the present hemiplegia) were recorded. A neurological room comes from), and for impairment of the examination with emphasis on degree of weakness, abstract attitude (by asking for interpretations of sensory loss and visual field defects was then five proverbs, each scored out of 2). The general, carried out. Weakness was rated on a four point neurological, and higher mental function assess- scale (1 =slight, 2=moderate, 3=severe, 4=total). ment will be referred to as the profile of a patient. Sensory loss was reCorded as present or absent; the An anosognosia questionnaire (Table 1) was extent and nature was noted and, although a crude designed to cover the range of anosognosic scale was drawn up, this was not included in the phenomena, and to probe anosognosia itself. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

550 John Cutting Table 1 A nosognosia questionnaire Anosognosia Anosognosic phenomena Procedure ifdenial elicited General questions on general questions Phenomenon Questions Why are you here? (Arm picked up) What is this? Anosodiaphoria Is it a nuisance? How much trouble does it cause you? What caused it? What is the matter with you? Can you lift it? Nonbelonging Do you ever feel that it doesn't belong? Is there anything wrong with your arm or You clearly have Do you feel that it belongs to someone leg? some problem else ? Is it weak, paralysed or numb? with this? Strange feelings Do you feel the arm is strange or odd? How does it feel? (Asked to lift arms) Can't you see Misoplegia Do you dislike the arm? Do you hate that the two arms it? are not at the Do you have strong feelings about it? same level? Personification Do you ever call it names? Kinaesthetic Do you ever feel it moves without hallucinations your moving it yourself? Overestimation How's the other arm? Phantom Do you ever feel a strange arm lying supernumerary beside you separate from the real arm? limb

Results hemiplegics, testable right hemiplegics, and left hemiplegics-are compared in Table 2. The main CHARACTERISTICS OF ENTIRE GROUP findings were that the testable group had less Fifty-two patients had a right hemiplegia. Of sensory disturbance, a lower incidence of field

these, 30 were so aphasic that it was impossible to defects, and fewer abnormalities of higher mental Protected by copyright. assess anosognosia. The remaining 22 had suffi- function. Language deficits were more common cient preservation of language for an assessment in right hemiplegics. Mood change was depressive to be carried out. They were free of receptive in right, but predominantly apathetic or euphoric aphasia but five had expressive difficulties. They in left hemiplegics. will be referred to as the "testable" group. Forty- eight patients had a left hemiplegia; none of these ANOSOGNOSIA had aphasia. The three groups-aphasic right Twenty-eight patients denied a left sided weakness

Table 2 Profiles of right aphasic, right testable, and left hemiplegic patients Right aphasic Right testable Left Number 30 22 48 Age 68 64 68 Sex (Y% male) 50% 55% 65% Left handers - 14% 10% Previous hemiplegia 8% 14% 8% Duration (days) 3.6 4.2 3.8 Degree of weakness 3.8 2.3 2.5 http://jnnp.bmj.com/ Sensory loss - 36% 88% Field defect - 9% 77% Disorientation - 32% 56% Mood-total abnormal - 23 % 56% -apathetic - 0% 36% -depressed - 23% 8 % -euphoric - 0% 12% Personal neglect - 0% 21% Visuospatial neglect - 0% 50% Visuoperceptual defect - 38% 53% mean score - 14.8 13.0 on September 26, 2021 by guest. Language-expressive dysfunction - 23 % 0% -abstract score - 2.0 3.9 Anosognosia - 14% 58% Anosognosic phenomena Total (no associated anosognosia) - 41 % 29% Anosodiaphoria - 9% 4% Nonbelonging - 14% 23% Strange sensations - 0% 6% Misoplegia - 23 % 4% Personification - 0% 2% Kinaesthetic hallucinations - 0% 4% Overestimation - 0% 4% Supernumerary phantom - 0% 0% J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

Study of anosognosia 551

(58% of left hemiplegics); there were three in- nuisance"). Personification was seen in one left stances of denial of a right hemiplegia (14% of hemiplegic. She claimed that the nurse had origin- testable, 6% of all right hemiplegics). There was ally called the leg "Fred," and she then called her a spectrum of attitudes, ranging from vehement arm "Little Fred;" she further stated that she denial that anything was wrong at all, to admission could be called "one-handed Pandy." Kinaesthetic that a stroke had occurred but denial that this had hallucinations occurred in two left hemiplegics. resulted. in limb weakness. Most would reluctantly One said that he "tried gripping, and if I am not agree that something was wrong, usually described looking, I feel as if I'm moving it, but when I as "stiffness" or "heaviness." Some patients, in look, I'm not." Neither denied their weakness. the course of the interview, would admit to weak- Overestimation of the strength of the unaffected ness, only to deny it minutes later. Others volun- arm occurred in two left hemiplegics. The cir- teered the fact that they had suffered a "stroke," cumstances were different in each case. One, al- often attributing the source of this information to though admitting to weakness in the left arm, the doctor. When questioned as to the effects of insisted that the examiner test the strength of his this "stroke," they denied weakness, and instead right arm, which he said was "very strong." gave some other consequence, for example a Another, with anosognosia, offered this increased "faint." A sample response is given. "Nothing strength as one of a series of inconsistent explana- wrong. Sometimes it's a bit stiff. It needs exercise. tions when faced with the falling away of his left Something hurts. Something aches." The be- arm. A supernumerary phantom limb was not haviour and statements of patients when cross- clearly identified in this study. Its presence might examined provided some insight into their thought have been inferred from the behaviour of one left processes. The impression gained was that by hemiplegic who fumbled in his axilla on cross- manipulating the situation one could achieve an examination. Protected by copyright. admission that there was some abnormality, but still fail to convince them that the explanation for GENERAL, NEUROLOGICAL, AND HIGHER MENTAL this was weakness in a limb. When presented with FUNCTION PROFILE overwhelming evidence, they resorted to evasion The profiles of three groups of patients are pre- ("Doctors know more about it than I do"), or in- sented in Table 3. Tests of significance (x2 or t consequential remarks ("I thought it was a stroke test, whichever appropriate) were used to compare once, but not now I've seen chaps in the ward anosognosics with those with phenomena only, and with them"). the latter with "normal" subjects.

ANOSOGNOSIC PHENOMENA General features Fourteen patients with a left hemiplegia (29%) Sex emerged as a moderately significant factor. showed anosognosic phenomena in the absence of Men were more likely to show anosognosia or a anosognosia itself; a further four demonstrated "normal" attitude, and women the phenomena. It both. Nine patients with a right hemiplegia (41% should be remarked that men were over-repre- in a of testable, 18 % of all) exhibited anosognosic sented the left hemiplegic group as a whole, http://jnnp.bmj.com/ phenomena. None had associated anosognosia. curious finding as the sex distribution for right Individual phenomena are described. Two patients hemiplegia was equal. Age distinguished those with a right, and two with a left hemiplegia with a "normal" attitude from other groups; the demonstrated anosodiaphoria. The experience of former were younger. Left handedness occurred nonbelonging of a limb was present in 11 left in some patients from all three groups, and no hemiplegics and three right hemiplegics. They conclusions can be drawn concerning the effect of offered motor ("It disobeyed me"), sensory ("I've laterality on the development of anosognosia. A

got no feeling"), or visual explanations ("My history of a previous hemiplegia was more com- on September 26, 2021 by guest. fingers shrank to short fat fingers"). Three mon in patients with phenomena and the duration patients, all left hemiplegics, attributed ownership of hemiplegia from onset was longer in the same to another person ("I felt it could have been a group. nurse's hand, a neighbour's, my wife's, a doctor's"). Strange sensations, not to the extent Neurological features of nonbelonging, were reported by three left Degree of weakness was compared across the hemiplegics ("lifeless," "cold and clammy"). groups, and cannot be said to affect the develop- Misoplegia was expressed by two left and five ment of an abnormal attitude. Sensory loss did right hemiplegics ("I'll hit it with a two-pound not emerge as a significant factor in the two com- hammer when I get back to work; its a bloody parisons, but there was a clear trend for its inci- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

552 John Cutting Table 3 Profiles of patients with aniosognosia, anosognosic phenomena, and a normal attitude

P P Anosognosia Phenomena Normal (anos/phen) (phenlnorm) Number 31 23 16 Sex (% male) 71% 43% 69% < 0.05 NS Age 70 68 60 NS < 0.01 Left handers 6% 13% 19% NS NS Previous hemiplegia 3 % 26% 6% < 0.05 NS Duration (days) 3.4 4.8 4.0 < 0.05 NS Degree of weakness 2.6 2.4 2.3 NS NS Sensory loss 87 % 65 % 38 % NS NS Field defect 90% 39% 19% < 0.001 NS Disorientation 71 % 43% 6% < 0.05 < 0.01 Mood-total abnormal 71 % 39 % 6% < 0.05 < 0.05 -apathy 51% 4% 0% < 0.001 NS -depression 10% 22% 6% NS NS -euphoria 10 % 13 % 0% NS NS Personal neglect 32 % 4% 0% < 0.05 NS Visuospatial neglect 52% 24 % 6% NS NS Visuoperceptual defect 86% 42% 6% <0.01 <0.05 meanscore 11.1 13.8 18.0 Abstract score 4.0 2.2 4.6 < 0.05 < 0.05 dence to diminish across the groups. Visual field crucial to the development of anosognosia itself, defect was a potent factor in discriminating be- but appears to play a part in at least some of the tween patients with anosognosia and those with its phenomena. phenomena. Protected by copyright. Discussion Higher mental functions The presence of disorientation significantly separ- INCIDENCE ated the three groups. Further analysis revealed An abnormal attitude towards a recent hemiplegia that in right hemiplegics, all three anosognosics was common with damage to either hemisphere. and four of the nine with phenomena were dis- Anosognosia and anosognosic phenomena were oriented; four of the remaining five with pheno- seen, respectively, in 58% and 29% of left hemi- mena were impaired on tests of attention or plegics, and in 14% and 40% of right hemiplegics. memory. In the left hemiplegics, a lower rate of The estimation of the incidence of anosognosia cognitive dysfunction prevailed. Of 28 anosog- for a left hemiplegia is slightly higher than that nosics, 19 were disoriented and a further four had of other authors, who give figures ranging from memory impairment; of 14 with phenomena, six 30% to 50%. Anosognosic patients in the present were disoriented and only a further one patient study were seen after only three to four days had had deficient memory. Mood change of any kind elapsed from the initial ictus, and this early exam- distinguished the groups to a significant extent; ination may have been responsible for the high apathy was virtually restricted to those with incidence. The other authors mentioned (Nathan- http://jnnp.bmj.com/ anosognosia, while euphoria and depression were son et al., 1952; Gross and Kaltenback, 1955; the forms predominantly seen in those with Ullman, 1962) recorded a longer mean interval phenomena. Personal neglect was only seen in one between the onset of the stroke and their assess- patient who did not have anosognosia, but only ment. As chronic hemiplegics rarely exhibit appeared in one-third of those with anosognosia. anosognosia (Gilliatt and Pratt, 1952), factors Visuospatial neglect failed to emerge as a signifi- unique to the acute stage of a cerebrovascular cant discriminator, but there was a trend for insult must be regarded as essential to the develop- anosognosics to show this more than other groups. ment of anosognosia. on September 26, 2021 by guest. Visuoperceptual deficit appeared a potent factor in separating anosognosia from those with pheno- LATERALITY mena. However, it was not entirely certain that The apparent difference between the incidence of failure to identify simple pictures reflected a pure an abnormal attitude towards a right (54%) and disturbance of visual perception, independent of left hemiplegia (87%) is complicated by the large such variables as neglect or inattention. Abstract group of 30 right hemiplegics who were aphasic. If language was considerably worse in those with all the aphasics are assumed to have held an phenomena, an unexpected finding which suggests abnormal attitude, not an unreasonable assump- that impairment of metaphorical abilities is not tion, then the figure for all right hemiplegics J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

Study of anosognosia 553 would rise to 81 %. It certainly appears that right tions allow a critical appraisal of the main theories hemisphere damage is not essential to the develop- concerning the nature of anosognosia. ment of an anosognosic attitude. There remains An emphasis on "confusion," accentuating a the question of whether it has a quantitatively or general tendency of ill people to repudiate their qualitatively different role than damage to the disability (Weinstein and Kahn, 1955; Ullman, left hemisphere. Only six of 48 left hemiplegics 1962), does not provide a comprehensive account were regarded as holding a normal attitude, while of anosognosia. A confusional state was not in- 10 of 22 testable right hemiplegics did so. This is variably associated with anosognosia and was not slender support for a quantitative difference be- infrequent in patients without this state. Anosog- tween hemispheres. Some of the findings lend at nosia is not adequately defined merely as "denial least meagre support to the idea that different of illness;" these patients would admit to a "heart factors may be responsible in each hemisphere. attack" and even a "stroke," but fail to appreciate For instance, left hemiplegics could develop weakness of a limb. Kinaesthetic hallucinations anosognosia or its phenomena in the absence of (Waldenstrom, 1939; Frederiks, 1969) cannot be disorientation or even impaired memory; in con- regarded as the fundamental element in the con- trast, all but one right hemiplegic with an abnor- dition. In the first place, only two patients re- mal attitude had obvious cognitive impairment. ported them, and neither had anosognosia itself. Secondly, there was evidence that visual factors ANOSOGNOSIC PHENOMENA (field defect, poor picture identification) were Although deficits in higher mental functions were more relevant than kinaesthetic factors. Further, more common in patients with phenomena than in when hemiparetic patients were asked to raise normals, they were less remarkable than in ano- both arms, those with anosognosia would accept sognosics. In the main, it appeared that general that they came to rest at different levels but fail to Protected by copyright. factors distinguished the two groups. Those with appreciate that this might indicate weakness of anosognosic phenomena were more likely to be one limb. It appeared that in this situation they women and to have had a previous hemiplegia; a could use some of the information pertaining to longer period had elapsed between the ictus and one side of the body but failed to integrate it into the author's examination than in the anosognosic a judgment about weakness. Unqualified adher- group. The last finding is in agreement with other ence to the idea of anosognosia as a "body image authors (Gilliatt and Pratt, 1952) that the pheno- disorder" with the implication of a right hemi- mena arise at a later stage in the resolution of a sphere "centre" (Bogen, 1969; Galin, 1974) is not stroke than anosognosia itself. There appears to consistent with the present results. The term be a sex difference in hemispheric distribution of "body image disorder" is, however, thoroughly language and visuospatial skills (McGlone and ambiguous, and while anosognosia can be accom- Kertesz, 1973), although it is difficult to relate modated by such a broad definition, the original the sex difference between anosognosia and its proposal of Head and Holmes (1911) of a "body phenomena to this. The previous hemiplegia might schema," essentially a physiological model which have provided an experience which rendered their could account for certain sensory deficits of cor- http://jnnp.bmj.com/ current state more understandable than to those tical origin, lacks the robustness necessary to ex- for whom a hemiplegia was a novel occurrence. plain the diverse manifestations observed in the Of the phenomena, anosodiaphoria and the experi- present series. ence of "nonbelonging" were the most likely to Psychodynamic, kinaesthetic, and "body image" show deficits of higher mental function, and had theories do not, therefore, provide satisfactory therefore the best claim to be regarded as "patho- accounts of anosognosia. Other suggestions can be logical attitudes." Misoplegia and some of the divided into two groups, which emphasise either rarer phenomena might be better regarded as "neglect" or "agnosia." "normal" adaptation phenomena (Critchley, 1953; Gross and Kaltenback (1955) introduced the on September 26, 2021 by guest. Frederiks, 1969). term "anosognosic complex" to describe the back- ground of neglect, apathy, and inattention out of PATHOGENESIS OF ANOSOGNOSIA which they believed that anosognosia developed. Deficits in higher mental function and field defect Denny-Brown et al. (1952) saw in anosognosia an were the most significant correlates of anosog- illustration of "amorphosynthesis," which they nosia. The higher level of significance obtained claimed was a fundamental characteristic of with field defect, apathetic mood, and visuoper- parietal lobe disease of either hemisphere, and ceptual deficit suggests that these should be re- which consists of a tendency to extinguish one garded as particularly important. These considera- member of a stimulus pair and to lose insight into J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. 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554 John Cutting perceptual processes. These are adequate descrip- In conclusion, I believe that the present study tions of much of anosognosic behaviour. The de- has advanced the understanding of anosognosia by velopment of unilateral neglect in monkeys pointing out the distinction between this and ano- (Kennard, 1939; Welch and Stuteville, 1958) and sognosic phenomena, and by examining the rela- in man (Heilman and Valenstein, 1972) from tionship with laterality of hemispheric damage. contralateral lesions in the frontal lobe provides a In demonstrating the significant association with relevant experimental model with which to com- certain other neuropsychological deficits, I have pare anosognosia. The deficit in these reports was indicated the poverty of some theoretical positions transient, affected stimuli from all sensory modali- and the relevance of others. In the present state ties and produced an apparent, but false, hemi- of knowledge, I believe that the two most com- anopia. There was "an apparent lack of recogni- prehensive approaches attribute anosognosia to tion of objects" attributed to "a disturbance of either "neglect" or agnosia. In favour of "neglect" the more complex integrative processes of the was the prominence of apathy in the present study frontal lobe" (Welch and Stuteville, 1958). The and the relevant animal experiments in the resemblance to anosognosia is striking. Each con- literature. I am, however, impressed by the associ- dition was transient, both visual and kinaesthetic ated visuoperceptual deficits and by the number sources of information were affected, and there of patients who appreciated morbid change but was a marked failure to identify pictures of simple failed, even in the absence of disorientation, to objects. However, a number of anosognosic arrive at a judgment of weakness, and favour, patients acknowledged the presence of morbid therefore, an agnosic basis for the condition. change in the affected limb and cannot be re- garded as demonstrating "neglect" unless one The material in this article is based on an MD broadens the concept to mean a failure to balance thesis awarded by the University of London. I Protected by copyright. information entering from the two sides (Denny- wish to thank Dr W. A. Lishman for much help Brown et al., 1952; Heilman and Valenstein, 1972). during the work, and the physicians and neurol- Interpreting "neglect" in this way, one can allo- ogists of the Brook General Hospital, London for cate patients to points along a spectrum, with, at allowing me to examine patients under their care. one end, severe forms giving rise to complete denial of any change in a limb, and, at the other, References minor forms where the experience of morbid Albert, M. L. (1973). A simple test of visual neglect. change is preserved but the capacity to make a Neurology (Minneapolis), 23, 658-64. judgment about the cause of this is disrupted in Anastasopoulos, G. K. (1961). Die nosoagnostische the central analysis. Uberschatzung. Psychiatria et Neurologia, 141, 214- Another approach is to regard the deficit as a 228. form Babinski, M. J. (1914). Contribution a l'etude des of agnosia. This idea was discussed by troubles mentaux dans l'hemiplegie organique cer& Sandifer (1946) and Roth (1949), and much of the brale. Revue Neurologique, 1, 845-84g. discussion on the nature of anosognosia, par- Bogen, J. E. (1969). The other side of the brain. ticularly the role of "confusion" and lower-order Bulletin of the Los A ngeles Neurological Society, http://jnnp.bmj.com/ sensory deficits, can be found in the literature on 34, 135-162. visual agnosia. Further, Geschwind (1965) argued Critchley, M. (1953). The Parietal Lobes. Arnold: that visual agnosia could be regarded as a lan- London. guage disorder and this point has been made for Critchley, M. (1962). Clinical investigation of disease anosognosia by Weinstein et al. (1964). A further of the parietal lobes of the brain. Medical Clinics of North America, 46, 837-857. comparison can be drawn between the nature of Denny-Brown, D., Meyer, J. S., and Horenstein, S. visual agnosia and anosognosia. In the former, a (1952). The significance of perceptual rivalry result- distinction has been made between "apperceptive"

ing from parietal lesions. Brain, 75, 433-471. on September 26, 2021 by guest. and "associational" forms (Taylor and Warring- Ehrenwald, H. (1930). Verandertes Erleben des ton, 1971), and applying this idea to anosognosia Korperbildes mit konsekutiver Wahnbildung bei it can be argued from the present results that most linksseitiger Hemiplegie. Monatsschrift fur Psychi- patients have normal apperception in their appre- atrie und Neurologie, 75, 89-97. ciation of morbid change, but disturbance in the Frederiks, J. A. M. (1969). Disorders of the body associational sphere by their faulty choice of schema. In Handbook of Clinical Neurology. Vol- ume 4. Edited by P. J. Vinken and G. W. Bruyn. linguistic term to express their experience. Others, North Holland: Amsterdam. comparatively few in this study, had little or no Galin, D. (1974). Implications for psychiatry of left appreciation of change in a limb and might be re- and right cerebral specialisation. Archives of garded as showing "apperceptive anosognosia." General Psychiatry, 31, 572-583. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.6.548 on 1 June 1978. Downloaded from

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