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