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Journal homepage: www.elsevier.com/locate/cortex
Centre for Health and Population Sciences, Hull York Medical School, University of Hull, UK
Department of Psychiatry, University of Cambridge, UK
article info
abstract
Article history:
The construction of anosognosia as a clinical disorder resulted from the convergence (in
the work of various writers and culminating in Babinski) of a name, a concept, and a
Started in the work of Anton, the process of separating it as a differentiable clinical state is
Keywords:
Anosognosia
Unawareness
Neurological dysfunction
Anton
Babinski
von Monakow
Insight
Neuropsychology
1.
Matters historiographical
changed during the last century; 3) included clinical phenomena3 with vague ontology4 (i.e., are they best defined as
events or as natural kinds?) and; 4) made use of explanatory
mechanisms ranging from agency to passivity (is anosognosia
the result of denial, self-deception,5 disconnection or
disruption of brain pathways?).
To deal with the historiography of such a nebulous clinical
notion the historian needs to resort to categories borrowed
from the sociology of knowledge6 and make use of a
convergence model. According to the latter, clinical categories result from the conjunction, at a given historical time,
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2.
3.
Descriptions of patients showing unawareness of neurological dysfunction (e.g., blindness, Redlich & Dorsey, 1945) can
be found before Babinski coined anosognosia in relation to
hemiplegia. Amongst others, unawareness was reported in
relation to blindness (Anton, 1899; Dejerine & Vialet, 1893; von
Monakow, 1885; Redlich & Bonvicini, 1911), deafness (Anton,
1899) and alexia (Bonhoeffer, 1903).
In the context of searching for correlations between clinical findings and brain lesions von Monakow (1885) described
4 patients with cortical blindness.
Case 1.
70 year old man who had been well until 4 years prior to
admission when he developed severe nose bleeds followed
by a left sided facial paralysis, left hemiplegia and mild
dysphasia. He had visual hallucinations and some visual
impairment. He recovered but was left with mild gait unsteadiness, mild visual impairment and subtle intellectual
impairment. The next year, following an epileptic seizure
he developed mild left sided facial and limb pareses and his
visual impairment became more obvious. Again he
improved and remained relatively well for 2 years. He then
began complaining that his eyesight was worsening and he
was experiencing difficulty with writing. At that time, he
complained of a thick fog in front of his eyes e blaming this
on bad weather. Ophthalmological examination was
normal. The next month following another apoplectic
attack he became completely blind as well as suffering
visual hallucinations, mobility problems and speech
problems (he could not understand the spoken word). His
mobility improved quickly. However, his blindness
remained and from this point on he was not aware of his
blindness. Initially he thought that he was in a dark pit or
cellar and shouted for light and fire. Later, he appeared to
have got accustomed to the visual hallucinations and so
the notion that he could not actually see anything did not
reach his awareness. He complained that he was old, stupid and weak e but he never articulated that he was blind.
This, together with the speech problem, gave the impression that he was totally confused and disorientated and
robbed him of the possibility of making sense of his environment. He often believed that he was outside the home
and demanded to go home. Although remaining well
kempt, empathic, and at times able to speak coherently,
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4.
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insisted that she did see the objects in front of her (despite
daily examinations disproving this). She also claimed that
she saw objects not presented to her. She was not aware of
her visual loss and this did not cause her concern or
distress or preoccupation. Her word finding difficulties
however did cause her obvious distress. She had lack of
spatial orientation but was able to localise touch, pain and
own body parts. She recognised people by voice and touch
but made no attempt to build up a visual image.
Case 8.
69 year old lady with cortical deafness. She was admitted to
the psychiatric unit because of confusion and agitation. At
that time she experienced a strong feeling of illness
(Krankheitsgefuhl) which later disappeared. She soon
became more settled. Upon admission it was evident that
she did not understand the spoken word and neither by
turning her head nor by answering did she react to this. Nor
did she react to clapping or loud noises or to shouting close
to her ears. Likewise she did not respond to bone conduction. She showed no understanding or interest in the examination. Her spontaneous speech was and remained
significantly impaired. She frequently chose wrong words
to express herself though sometimes she would start with
the right beginning of a word. Her speech showed
abnormal grammatical construction. She could read relatively well and this together with gesturing was the only
way communication could occur. She frequently repeated
syllables and words. She recognised people around her by
sight and named objects put before her mostly correctly.
She was also able to find the right name for touch and body
sensation. She complained frequently of her bronchitis as
well as her short-sightedness. Concerning her hearing loss
however she never complained and remained completely
indifferent to it. During conversations she was also never
aware that she could not hear nor understand the questions put to her. What she answered was nothing other
than a continuation of her own thoughts. She was
repeatedly asked (by writing) whether she could hear and
she firmly answered that she could hear well. It was
remarkable that despite the severe unawareness of her
hearing loss, she was aware of her problem with using
wrong words and tried to correct this.
Anton tried to relate these clinical states to detailed postmortem findings in an attempt to determine the relationship
between unawareness of the neurological dysfunction and
damaged brain areas. In contrast to the earlier descriptions
found in von Monakow or Dejerine, he differentiated the
unawareness of dysfunction as an independent symptom or
state and conceptualised it as a phenomenon in its own right.
This, he sought to understand clinically, by exploring in more
detail patients' descriptions and behaviours, as well as pathologically by seeking to link these with neuro-anatomical
changes. He emphasised the selective nature of the unawareness, that is, patients were unaware of their hearing or
visual loss but were distressed by relatively minor problems
such as word finding difficulties; and observed that the unawareness might encompass more than the hearing or visual
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5.
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6.
Although the cases reported above all fall within the broad
category of anosognosia they also show a great deal of difference in regards to their background complaints such as
confusion, cognitive impairment and psychotic symptoms. It
is the case that most of these patients seemed unaware of one
of their disabilities, usually a dramatic sensory or motor
disability. Although more than one clinician participated in
the construction of anosognosia, Babinski seems to be the one
celebrated in this context. This may be due to the fact that in
addition to coining the name he offered a semiological
perspective that emphasized the separation of unawareness
as a phenomenon. This has driven much of subsequent
research in this area (Prigatano, 2010) and contributed to its
stability.
The idea that failures of awareness can be an independent
condition has had various consequences. For example, it has
legitimized the idea that awareness (the entity that fails in
unawareness) can be conceptualized and studied as an independent function in neuropsychology (Bisiach, Vallar, Perani,
Papagno, & Berti, 1986; McGlynn & Schacter, 1989). Focussing
attention on unawareness is also likely to have encouraged
detailed clinical observation and this has led to identifying a
host of anosognosia-like phenomena (Cutting, 1978). In the
same vein, the view that unawareness may be an independent phenomenon has opened the door to all manner of accounts including denial (Weinstein & Kahn, 1955) which
radically changes the old meaning of anosognosia by introducing a participatory agency on the part of the person.
There has not been the space here to consider the historical
construction of awareness (or insight) into madness. Debates
concerning the question of patients' awareness or their
madness were already taking place some fifty years earlier
, 2004). Constructed in parallel and arising
(Berrios & Markova
from a different direction and perspective, the phenomenon
of awareness into madness carried a very different structure
, 2005; Markova
& Berrios, 2011). In recent years there
(Markova
has however been a convergence of these approaches with the
assumption that the clinical phenomena of anosognosia and
lack of insight are equivalent (e.g., Mullen et al., 1996). In the
light of the analysis here, the validity of such a convergence
has to be questionable. However, it is only through understanding how a new clinical condition is constructed and
what factors are involved in such construction that sense can
be made of its structure and meaning. For that reason an
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Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.cortex.2014.09.011.
references
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further reading
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