Background: Anosognosia in stroke patients showed a relevant detrimental effect on the rehabilitation course and patients’ quality of life, especially in those with brain injury. Although a number of reliable scales for the assessment of anosognosia in stroke and traumatic brain injury have been developed, at present no single measure fully explores the multifaceted nature of the phenomenon. Method: A PubMed search with appropriate terms was carried out in order to critically review the issue. Results: The main dimensions to consider in the investigation of anosognosia in brain-injured patients are (a) awareness of deficit and related functional implications, (b) modality specificity, (c) causal attribution, (d) expectations of recovery, (e) implicit knowledge and (f) differential diagnosis with psychological denial. Time elapsed from stroke, aetiology, laterality, aphasia and clinical complications may influence all these characteristics and must be taken into consideration. Finally, an adequate association of the anosognosia evaluation with other neuropsychological and behavioural aspects is relevant for a modern holistic approach to the patient. Conclusions: This review is meant to stimulate the development of a new comprehensive assessment procedure for anosognosia in brain injury and particularly in stroke, in order to catch the multidimensionality of the phenomenon and to shape rehabilitation programmes suitable to the specific clinical features of every single patient.

Keywords:
Anosognosia, assessment, Stroke rehabilitation
1.
Antoine C, Antoine P, Guermonprez P, Frigard B: Awareness of deficits and anosognosia in Alzheimer’s disease. Encéphale 2004;30:570–577.
2.
Prigatano G, Johnson S: The three vectors of consciousness and their disturbances after brain injury. Neuropsychol Rehabil 2003;13:13–29.
3.
Orfei MD, Robinson RG, Prigatano GP, Starkstein S, Rüsch N, Bria P, Caltagirone C, Spalletta G: Anosognosia for hemiplegia after stroke is a multifaceted phenomenon: a systematic review of the literature. Brain 2007;130:3075–3090.
4.
Fleming JM, Strong J, Ashton R: Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Inj 1996;10:1–15.
5.
Gialanella B, Monguzzi V, Santoro R, Rocchi S: Functional recovery after hemiplegia in patients with neglect: the rehabilitative role of anosognosia. Stroke 2005;36:2687–2690.
6.
Pedersen PM, Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS: Frequency, determinants and consequences of anosognosia in acute stroke. J Neurol Rehabil 1996;40:367–377.
7.
Crosson C, Barco PP, Velozo C, Bolesta MM, Cooper PV, Werts D, Brobeck TC: Awareness and compensation in postacute head injury rehabilitation. J Head Trauma Rehabilitation 1989;4:46–54.
8.
Starkstein SE, Fedoroff JP, Price TR, Leiguarda R, Robinson RG: Anosognosia in patients with cerebrovascular lesions: a study of causative factors. Stroke 1992;23:1446–1453.
9.
Stone SP, Halligan PW, Greenwood RJ: The incidence of neglect phenomena and related disorders in patients with an acute right or left hemisphere stroke. Age Ageing 1993;22:46–52.
10.
Ramachandran VS: Anosognosia in parietal lobe syndrome. Conscious Cogn 1995;4:22–51.
11.
Maeshima S, Dohi N, Funahashi K, Nakai K, Itakura T, Komai N: Rehabilitation of patients with anosognosia for hemiplegia due to intracerebral haemorrhage. Brain Inj 1997;11:691–697.
12.
Jehkonen M, Ahonen JP, Dastidar P, Laippala P, Vilkki J: Unawareness of deficits after right hemisphere stroke: double-dissociations of anosognosias. Acta Neurol Scand 2000;102:378–384.
13.
Hartman-Maeir A, Soroker N, Katz N: Anosognosia for hemiplegia in stroke rehabilitation. Neurorehabil Neural Repair 2001;15:213–222.
14.
Appelros P, Karlsson GM, Seiger A, Nydevik I: Neglect and anosognosia after first-ever stroke: incidence and relationship to disability. J Rehabil Med 2002;34:215–220.
15.
Appelros P, Karlsson GM, Seiger A, Nydevik I: Prognosis for patients with neglect and anosognosia with special reference to cognitive impairment. J Rehabil Med 2003;35:254–258.
16.
Hartman-Maeir A, Soroker N, Oman SD, Katz N: Awareness of disabilities in stroke rehabilitation – a clinical trial. Disabil Rehabil 2003;25:35–44.
17.
Farnè A, Buxbaum LJ, Ferraro M, Frassinetti F, Whyte J, Veramonti T, Angeli V, Coslett HB, Ladavas E: Patterns of spontaneous recovery of neglect and associated disorders in acute right brain-damaged patients. J Neurol Neurosurg Psychiatry 2004;75:1401–1410.
18.
Marcel AJ, Tegner R, Nimmo-Smith I: Anosognosia for plegia: specificity, extension, partiality and disunity of bodily unawareness. Cortex 2004;40:19–40.
19.
Baier B, Karnath HO: Incidence and diagnosis of anosognosia for hemiparesis revisited. J Neurol Neurosurg Psychiatry 2005;76:358–361.
20.
Berti A, Bottini G, Gandola M, Pia L, Smania N, Stracciari A, Castiglioni I, Vallar G, Paulesu E: Shared cortical anatomy for motor awareness and motor control. Science 2005;309:488–491.
21.
Karnath HO, Baier B, Nagele T: Awareness of the functioning of one’s own limbs mediated by the insular cortex? J Neurosci 2005;25:7134–7138.
22.
Nimmo-Smith I, Marcel AJ, Tegner R: A diagnostic test of unawareness of bilateral motor task abilities in anosognosia for hemiplegia. J Neurol Neurosurg Psychiatry 2005;76:1167–1169.
23.
Barskova T, Wilz G: Psychosocial functioning after stroke: psychometric properties of the patient competency rating scale. Brain Inj 2006;20:1431–1437.
24.
Santos CO, Caeiro L, Ferro JM, Albuquerque R, Luisa Figueira M: Anger, hostility and aggression in the first days of acute stroke. Eur J Neurol 2006;13:351–358.
25.
Appelros P, Karlsson GM, Hennerdal S: Anosognosia versus unilateral neglect. Coexistence and their relations to age, stroke severity, lesion site and cognition. Eur J Neurol 2007;14:54–59.
26.
Spalletta G, Serra L, Fadda L, Ripa A, Bria P, Caltagirone C: Unawareness of motor impairment and emotions in right hemispheric stroke: a preliminary investigation. Int J Geriatr Psychiatry 2007;22:1241–1246.
27.
Prigatano GP, Altman IM: Impaired awareness of behavioral limitations after traumatic brain injury. Arch Phys Med Rehabil 1990;71:1058–1064.
28.
Sherer M, Bergloff P, Boake C, High W Jr, Levin E: The Awareness Questionnaire: factor structure and internal consistency. Brain Inj 1998;12:63–68.
29.
Leathem JM, Murphy LJ, Flett RA: Self and informant-ratings on the Patient Competency Rating Scale in patients with traumatic brain injury. J Clin Exp Neuropsychol 1998;20:694–705.
30.
Fleming JM, Strong J, Ashton R: Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome. J Head Trauma Rehabil 1998;13:39–51.
31.
Ranseen JD, Bhaska LA, Schmitt FA: An investigation of anosognosia following traumatic head injury. Int J Clin Neuropsychol 1990;12:29–36.
32.
Sherer M, Hart T, Nick TG: Measurement of impaired self-awareness after traumatic brain injury: a comparison of the Patient Competency Rating Scale and the Awareness Questionnaire. Brain Inj 2003;17:25–37.
33.
Bogod NM, Mateer CA, MacDonald SWS: Self-awareness after traumatic brain injury: a comparison of measures and their relationship to executive functions. J Int Neuropsychol Soc 2003;9:450–458.
34.
Hart T, Sherer M, Whyte J, Polansky M, Novack TA: Awareness of behavioral, cognitive, and physical deficits in acute traumatic brain injury. Arch Phys Med Rehabil 2004;85:1450–1456.
35.
Evans CC, Sherer M, Nick TG, Nakase-Richardson R, Yablon SA: Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury. J Head Trauma Rehabil 2005;20:488–500.
36.
Murrey GJ, Hale FM, Williams JD: Assessment of anosognosia in persons with frontal lobe damage: clinical utility of the Mayo-Portland adaptability inventory (MPAI). Brain Inj 2005;19:599–603.
37.
Sawchyn JM, Mateer CA, Suffield JB: Awareness, emotional adjustment, and injury severity in postacute brain injury. J Head Trauma Rehabil 2005;20:301–314.
38.
Sherer M, Hart T, Whyte J, Nick TG, Yablon SA: Neuroanatomic basis of impaired self-awareness after traumatic brain injury. J Head Trauma Rehabil 2005;20:287–300.
39.
Kurtz JE, Putnam SH: Patient-informant agreement on personality ratings and self-awareness after head injury. Clin Neuropsychol 2006;20:453–468.
40.
Schmitz TW, Rowley HA, Kawahara TN, Johnson SC: Neural correlates of self-evaluative accuracy after traumatic brain injury. Neuropsychologia 2006;44:762–773.
41.
Pagulayan KF, Temkin NR, Machamer JE, Dikmen SS: The measurement and magnitude of awareness difficulties after traumatic brain injury: a longitudinal study. J Int Neuropsychol Soc 2007;13:561–570.
42.
Dirette DK, Plaisier BR: The development of self-awareness of deficits from 1 week to 1 year after traumatic brain injury: preliminary findings. Brain Inj 2007;21:1131–1136.
43.
Bisiach E, Vallar G, Perani D, Papagno C, Berti A: Unawareness of disease following lesions of the right hemisphere: anosognosia for hemiplegia and anosognosia for hemianopia. Neuropsychologia 1986;24:471–482.
44.
Teasdale TW, Christensen AL, Willmes K, Deloche G, Braga L, Stachowiak F, Vendrell JM, Castro-Caldas A, Laaksonen RK, Leclercq M: Subjective experience in brain-injured patients and their close relatives: a European Brain Injury Questionnaire study. Brain Inj 1997;11:543–563.
45.
Borgaro SR, Prigatano GP: Modification of the Patient Competency Rating Scale for use on an acute neurorehabilitation unit: the PCRS-NR. Brain Inj 2003;17:847–853.
46.
Kortte KB, Wegener ST, Chwalisz K: Anosognosia and denial: their relationship to coping and depression in acquired brain injury. Rehabil Psychol 2003;48:131–136.
47.
Fischer S, Gauggel S, Trexler LE: Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries. Brain Inj 2004;18:547–562.
48.
Fischer S, Trexler LE, Gauggel S: Awareness of activity limitations and prediction of performance in patients with brain injuries and orthopedic disorders. J Int Neuropsychol Soc 2004;10:190–199.
49.
Noé E, Ferri J, Caballero MC, Villodre R, Sanchez A, Chirivella J: Self-awareness after acquired brain injury: predictors and rehabilitation. J Neurol 2005;252:168–175.
50.
Orfei MD, Robinson RG, Bria P, Caltagirone C, Spalletta G: Unawareness of illness in neuropsychiatric disorders: phenomenological certainty versus etiopathogenic vagueness. Neuroscientist 2008;14:203–222.
51.
Cutting J: Study of anosognosia. J Neurol Neurosurg Psychiatry 1978;41:548–555.
52.
Feinberg TE, Roane DM, Ali J: Illusory limb movements in anosognosia for hemiplegia. J Neurol Neurosurg Psychiatry 2000;68:511–513.
53.
Babinski J: Contribution à l’étude de troubles mentaux dans l’hémiplégie organique cérébrale. Rev Neurol 1914;27:845–847.
54.
Frith CD, Blakemore SJ, Wolpert DM: Abnormalities in the awareness and control of action. Philos Trans R Soc Lond B Biol Sci 2000;355:1771–1788.
55.
Heilman KM, Barrett AM, Adair JC: Possible mechanisms of anosognosia: a defect in self-awareness. Philos Trans R Soc Lond B Biol Sci 1998;353:1903–1909.
56.
Vallar G, Ronchi R: Anosognosia for motor and sensory deficits after unilateral brain damage: a review. Restor Neurol Neurosci 2006;24:247–257.
57.
Vuilleumier P: Anosognosia: the neurology of beliefs and uncertainties. Cortex 2004;40:9–17.
58.
Bach LJ, David AS: Self-awareness after acquired and traumatic brain injury. Neuropsychol Rehabil 2006;16:397–414.
59.
Fischer S, Gauggel S, Trexler LE: Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries. Brain Inj 2004;18:547–562.
60.
Schacter DL: Toward a cognitive neuropsychology of awareness: implicit knowledge and anosognosia. J Clin Exp Neuropsychol 1990;12:155–178.
61.
Fischer S, Trexler LE, Gauggel S: Awareness of activity limitations and prediction of performance in patients with brain injuries and orthopedic disorders. J Int Neuropsychol Soc 2004;10:190–199.
62.
Hart T, Giovannetti T, Montgomery MW, Schwartz MF: Awareness of errors in naturalistic action after traumatic brain injury. J Head Trauma Rehabil 1998;13:16–28.
63.
Brozzoli C, Dematte ML, Pavani F, Frassinetti F, Farne A: Neglect and extinction: within and between sensory modalities. Restor Neurol Neurosci 2006;24:217–232.
64.
Prigatano GP, Klonoff PS: A clinician’s rating scale for evaluating impaired self-awareness and denial of disability after brain injury. Clin Neuropsychol 1998;12:56–67.
65.
Prigatano GP, Schacter DL: Awareness of Deficit after Brain Injury: Clinical and Theoretical Issues. New York, Oxford University Press, 1991.
66.
Pia L, Neppi-Modona M, Ricci R, Berti A: The anatomy of anosognosia for hemiplegia: a meta-analysis. Cortex 2004;40:367–377.
67.
Jehkonen M, Laihosalo M, Kettunen JE: Impact of neglect on functional outcome after stroke: a review of methodological issues and recent research findings. Restor Neurol Neurosci 2006;24:209–215.
68.
Prigatano GP, Borgaro S, Baker J, Wethe J: Awareness and distress after traumatic brain injury: a relative’s perspective. J Head Trauma Rehabil 2005;20:359–367.
69.
Godfrey HP, Harnett MA, Knight RG, Marsh NV, Kesel DA, Partridge FM, Robertson RH: Assessing distress in caregivers of people with a traumatic brain injury (TBI): a psychometric study of the Head Injury Behaviour Scale. Brain Inj 2003;17:427–435.
70.
Hannesdottir K, Morris RG: Primary and secondary anosognosia for memory impairment in patients with Alzheimer’s disease. Cortex 2007;43:1020–1030.
71.
Jehkonen M, Laihosalo M, Kettunen J: Anosognosia after stroke: assessment, occurrence, subtypes and impact on functional outcome reviewed. Acta Neurol Scand 2006;114:293–306.
72.
Lindell AB, Jalas MJ, Tenovuo O, Brunila T, Voeten MJ, Hamalainen H: Clinical assessment of hemispatial neglect: evaluation of different measures and dimensions. Clin Neuropsychol 2007;21:479–497.
73.
Marin RS, Biedrzycki RC, Firinciogullari S: Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res 1991;38:143–162.
74.
Prigatano GP, Fordyce DJ, Zeiner HK, Roueche JR, Pepping M, Wood BC: Neuropsychological Rehabilitation after Brain Injury. Baltimore, Johns Hopkins University Press, 1986.
75.
Bagby RM, Taylor GJ, Parker JD: The Twenty-Item Toronto Alexithymia Scale. II. Convergent, discriminant, and concurrent validity. J Psychosom Res 1994;38:33–40.
76.
Levine J, Warrenburg S, Kerns R, Schwartz G, Delaney R, Fontana A, Gradman A, Smith S, Allen S, Cascione R: The role of denial in recovery from coronary heart disease. Psychosom Med 1987;49:109–117.
77.
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;12:56–62.
78.
Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50–55.
79.
Spielberger CD, Gorsuch RL, Lurshene RE: Test Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, Consulting Psychologists Press, 1970.
80.
Spielberger CD: State-Trait Anger Expression Inventory, Research Edition – Professional Manual. Odessa, Psychological Assessment Resources, 1988.
81.
Folstein MF, Folstein SE, McHugh PR: ‘Mini-Mental State’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–198.
82.
Wechsler D: WAIS-R Manual: Wechsler Adult Intelligence Scale – Revised. San Antonio, Psychological Corporation, 1981.
83.
Davies M, Davies AA, Coltheart M: Anosognosia and the two-factor theory of delusions. Mind Lang 2005;20:209–236.
84.
Levine DN, Calvanio R, Rinn WE: The pathogenesis of anosognosia for hemiplegia. Neurology 1991;41:1770–1781.
85.
Stroop JR: Studies of interference in serial verbal reactions. J Exp Psychol 1935;12:643–662.
86.
Heaton R: Wisconsin Card Sorting Test Manual. Odessa, Psychological Assessment Resources, 1981.
87.
Kashiwa Y, Kitabayashi Y, Narumoto J, Nakamura K, Ueda H, Fukui K: Anosognosia in Alzheimer’s disease: association with patient characteristics, psychiatric symptoms and cognitive deficits. Psychiatry Clin Neurosci 2005;59:697–704.
88.
Michon A, Deweer B, Pillon B, Agid Y, Dubois B: Relation of anosognosia to frontal lobe dysfunction in Alzheimer’s disease. J Neurol Neurosurg Psychiatry 1994;57:805–809.
89.
Subotnik KL, Nuechterlain KH, Irzhevsky V, Kitchen CM, Woo SM, Mintz J: Is unawareness of psychotic disorder a neurocognitive or psychological defensiveness problem? Schizophr Res 2005;75:147–157.
90.
Shad MU, Muddasani S, Prasad K, Sweeney JA, Keshavan MS: Insight and prefrontal cortex in first-episode schizophrenia. Neuroimage 2004;22:1315–1320.
91.
Spalletta G, Ripa A, Bria P, Caltagirone C, Robinson RG: Response of emotional unawareness after stroke to antidepressant treatment. Am J Geriatr Psychiatry 2006;14:220–227.
92.
Brodaty H, Sachdev PS, Withall A, Altendorf A, Valenzuela MJ, Lorentz L: Frequency and clinical, neuropsychological and neuroimaging correlates of apathy following stroke – the Sydney Stroke Study. Psychol Med 2005;35:1707–1716.
93.
Hama S, Yamashita H, Shigenobu M, Watanabe A, Hiramoto K, Kurisu K, Yamawaki S, Kitaoka T: Depression or apathy and functional recovery after stroke. Int J Geriatr Psychiatry 2007;22:1046–1051.
94.
Ghika-Schmid F, Bogousslavsky J: Affective disorders following stroke. Eur Neurol 1997;38:75–81.
95.
Kim JS, Choi S, Kwon SU, Seo YS: Inability to control anger or aggression after stroke. Neurology 2002;58:1106–1108.
96.
Spalletta G, Pasini A, Costa A, De Angelis D, Ramundo N, Paolucci S, Caltagirone C: Alexithymic features in stroke: effects of laterality and gender. Psychosom Med 2001;63:944–950.
97.
Flashman LA, McAllister TW, Johnson SC, Rick JH, Green RL, Saykin AJ: Specific frontal lobe subregions correlated with unawareness of illness in schizophrenia: a preliminary study. J Neuropsychiatry Clin Neurosci 2001;13:255–257.
98.
Ruby P, Schmidt C, Hogge M, D’Argembeau A, Collette F, Salmon E: Social mind representation: where does it fail in frontotemporal dementia? J Cogn Neurosci 2007;19:671–683.
99.
Shad MU, Muddasani S, Keshavan MS: Prefrontal subregions and dimensions of insight in first-episode schizophrenia – a pilot study. Psychiatry Res 2006;146:35–42.
100.
Schaechter JD, Moore CI, Connell BD, Rosen BR, Dijkhuizen RM: Structural and functional plasticity in the somatosensory cortex of chronic stroke patients. Brain 2006;129:2722–2733.
© 2009 S. Karger AG, Basel
2009
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.