Skip to main content

Advertisement

Log in

Disorders of awareness in neuropsychiatric syndromes: An update

  • Published:
Current Psychiatry Reports Aims and scope Submit manuscript

Abstract

Impaired awareness has been reported in a number of neuropsychiatric disorders. The purpose of this review is to provide an update on the current understanding of impaired awareness in neuropsychiatric syndromes, including Alzheimer’s disease (AD), Parkinson’s disease (PD), Huntington’s disease (HD), traumatic brain injury (TBI), schizophrenia, mood disorders, and obsessive-compulsive disorder (OCD). Unawareness of illness or deficits can have important diagnostic, treatment, and functional implications, and further understanding of its clinical and neural correlates will be extremely helpful in mediating its impact. Nevertheless, the area of unawareness has received relatively little attention as compared with other manifestations of neuropsychiatric illness. Evidence supporting a role for the involvement of frontal and parietal lobes across disorders is presented. Although most research has used neuropsychologic measures to assess brain functioning, more recent, limited literature in AD and schizophrenia has begun to examine neural correlates of unawareness using structural and functional imaging.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

  1. Stuss DT, Benson DF: The Frontal Lobes. New York: Raven Press; 1986.

    Google Scholar 

  2. Benson DF, Stuss DT: Frontal lobe influences on delusions: a clinical perspective. Schizophr Bull 1990, 16:403–411.

    PubMed  CAS  Google Scholar 

  3. Tournois J, Mesnil F, Kop J-L: Self-deception and otherdeception: a social desirability questionnaire. Eur Rev Appl Psychology 2000, 50:219–233.

    Google Scholar 

  4. Sackeim HA, Wegner AZ: Attributional patterns in depression and euthymia. Arch Gen Psychiatry 1986, 43:553–560.

    PubMed  CAS  Google Scholar 

  5. Kotler-Cope S, Camp CJ: Anosognosia in Alzheimer’s disease. Alzheimer Dis Assoc Disord 1995, 9:52–56.

    Article  PubMed  CAS  Google Scholar 

  6. Flashman LA, Amador X, McAllister TW: Lack of awareness of deficits in traumatic brain injury. Semin Clin Neuropsychiatry 1998, 3:201–210.

    PubMed  Google Scholar 

  7. Vasterling JJ, Seltzer B, Watrous WE: Longitudinal assessment of deficit unawareness in Alzheimer’s disease. Neuropsychiatry Neuropsychol Behav Neurol 1997, 10:197–202.

    PubMed  CAS  Google Scholar 

  8. Derouesne C, Thibault S, Lagha-Pierucci S, et al.: Decreased awareness of cognitive deficits in patients with mild dementia of the Azheimer type. Int J Geriatr Psychiatry 1999, 14:1019–1030. This was one of the few studies that used SPECT scanning to characterize the relationship between unawareness and perfusion deficit profile in patients with mild Alzheimer’s disease. Results confirmed the relationship between deficits in awareness and decreased frontal lobe perfusion.

    Article  PubMed  CAS  Google Scholar 

  9. Harwood DG, Sultzer DL, Wheatley MV: Impaired insight in Alzheimer’s disease: Association with cognitive deficits, psychiatric symptoms, and behavioral disturbances. Neuropsychiatry Neuropsychol Behav Neurol 2000, 13:83–88.

    PubMed  CAS  Google Scholar 

  10. Feher EP, Mahurin RK, Inbody SB, et al.: Anosognosia in Alzheimer’s disease. Neuropsychiatry Neuropsychol Behav Neurol 1991, 4:136–146.

    Google Scholar 

  11. Migliorelli R, Teson A, Sabe L, et al.: Anosognosia in Alzheimer’s disease: a study of associated factors. J Neuropsychiatry 1995, 7:338–344.

    CAS  Google Scholar 

  12. Reed BR, Jagust WJ, Coulter L: Anosognosia in Alzheimer’s disease: relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol 1993, 15:231–244. This was the first study in patients with AD that attempted to demonstrate neural correlates of unawareness of illness. The authors examined rCBF with SPECT scanning, and found diminished relative right dorsolateral frontal lobe perfusion in AD patients with awareness deficits. They also reported that awareness deficits were associated with high rates of false positive errors on recognition memory testing.

    PubMed  CAS  Google Scholar 

  13. Sevush S, Leve N: Denial of memory deficit in Alzheimer’s disease. Am J Psychiatry 1993, 150:748–751.

    PubMed  CAS  Google Scholar 

  14. Sevush S: Relationship between denial of memory deficit and dementia severity in Alzheimer disease. Neuropsychiatry Neuropsychol Behav Neurol 1999, 12:89–94.

    Google Scholar 

  15. Mangone CA, Hier DB, Gorelick PB, et al.: Impaired insight in Alzheimer’s disease. J Geriatr Psychiatry Neurol 1991, 4:189–193.

    PubMed  CAS  Google Scholar 

  16. Ott BR, Lafleche G, Whelihan WM, et al.: Impaired awareness of deficits in Alzheimer disease. Alzheimer Dis Assoc Disord 1996, 10:68–76.

    Article  PubMed  CAS  Google Scholar 

  17. Starkstein SE, Chemerinski E, Sabe L, et al.: Prospective longitudinal study of depression and anosognosia in Alzheimer’s disease. Br J Psychiatry 1997, 171:47–52.

    PubMed  CAS  Google Scholar 

  18. Auchus AP, Goldstein FC, Green J, et al.: Unawareness of cognitive impairments in Alzheimer’s disease. Neuropsychiatry Neuropsychol Behav Neurol 1994, 7:25–29.

    Google Scholar 

  19. Michon A, Deweer B, Pillon B, et al.: Relation of anosognosia to frontal lobe dysfunction in Alzheimer’s disease. J Neurol Neurosurg Psychiatry 1994, 57:805–809.

    PubMed  CAS  Google Scholar 

  20. Smith CA, Henderson VW, McCleary CA, et al.: Anosognosia and Alzheimer’s disease: the role of depressive symptoms in mediating impaired insight. J Clin Exp Neuropsychol 2000, 22:437–444.

    PubMed  CAS  Google Scholar 

  21. Starkstein SE, Vazquez S, Migliorelli R, et al.: A single-photon emission computed tomographic study of anosognosia in Alzheimer’s disease. Arch Neurol 1995, 52:415–420. This study was the second SPECT study examining blood flow correlates of unawareness in patients with AD. Despite a lack of between-group differences on measures on neuropsychologic tasks, AD patients with awareness deficits showed significant blood flow deficits in the frontal inferior and superior (dorsal) areas of the right hemisphere.

    PubMed  CAS  Google Scholar 

  22. Lopez OL, Becker JT, Somsak D, et al.: Awareness of cognitive deficits and anosognosia in probable Alzheimer’s Disease. Eur Neurol 1994, 34:277–282.

    PubMed  CAS  Google Scholar 

  23. Reisberg B, Gordon B, McCarthy M, et al.: Clinical symptoms accompanying progressive cognitive decline and Alzheimer’s disease. In Alzheimer’s Dementia. Edited by Melnick VL, Dubler NN. Clifton, NJ: Humana Press; 1985.

    Google Scholar 

  24. Starkstein SE, Sabe L, Cuerva AG, et al.: Anosognosia and procedural learning in Alzheimer’s disease. Neuropsychiatry Neuropsychol Behav Neurol 1997, 10:96–101.

    PubMed  CAS  Google Scholar 

  25. Starkstein SE, Sabe L, Petracca G, et al.: Neuropsychological and psychiatric differences between Alzheimer’s disease and Parkinson’s disease with dementia. J Neurol Neurosurg Psychiatry 1996, 61:381–387.

    PubMed  CAS  Google Scholar 

  26. Seltzer B, Vasterling JJ, Mathias CW, et al.: Clinical and neuropsychological correlates of impaired awareness of deficits in Alzheimer disease and Parkinson disease: a comparative study. Neuropsychiatry Neuropsychol Behav Neurol 2001, 14:122–129.

    PubMed  CAS  Google Scholar 

  27. Vitale C, Pellecchia MT, Grossi D, et al.: Unawareness of dyskinesias in Parkinson’s and Huntington’s diseases. Neurol Sci 2001, 22:105–106.

    Article  PubMed  CAS  Google Scholar 

  28. Hans MB, Gilmore TH: Social aspects of Huntingon’s chorea. Br J Psychiatry 1968, 114:93–98.

    Article  PubMed  CAS  Google Scholar 

  29. Deckel AW, Morrison D: Evidence of a neurologically based "denial of illness" in patients with Huntington’s disease. Arch Clin Neuropsychol 1996, 11:295–302.

    Article  PubMed  CAS  Google Scholar 

  30. Freeland J: Awareness of deficits: a complex interplay of neurological, personality, social and rehabilitation factors. Magazine 1996, 4:32–34.

    Google Scholar 

  31. McKinlay WW, Brooks DN: Methodological problems in assessing psychosocial recovery following severe head injury. J Clin Neuropsychol 1984, 6:97–99.

    Google Scholar 

  32. Thomsen IV: The patient with severe head injury and his family. Scand J Rehab Med 1974, 6:180–183.

    CAS  Google Scholar 

  33. Kozloff R: Networks of social support and the outcome from severe head injury. J Head Trauma Rehab 1987, 2:14–23.

    Google Scholar 

  34. Prigatano GP, Klonoff PS, Bailey I: Psychosocial adjustment associated with traumatic brain injury: Statistics BNI neurorehabilitation must beat. BNI Q 1987, 3:10–17.

    Google Scholar 

  35. Dikmen SS, Machamer JE, Winn HR, et al.: Neuropsychological outcome at 1-year post head injury. Neuropsychology 1995, 9:80–90.

    Article  Google Scholar 

  36. Levin HS, Gary HE, Eisenberg HM, et al.: Neurobehavioral outcome 1 year after severe head trauma: experience of the Traumatic Coma Data Bank. J Neurosurg 1990, 73:699–709.

    PubMed  CAS  Google Scholar 

  37. Prigatano GP, Altman IM: Impaired awareness of behavioral limitations after traumatic brain injury. Arch Physical Med Rehab 1990, 71:1058–1064.

    CAS  Google Scholar 

  38. Prigatano GP, Bruna O, Mataro M, et al.: Initial disturbances of consciousness and resultant impaired awareness in Spanish patients with traumatic brain injury. J Head Trauma Rehab 1998, 13:29–38.

    CAS  Google Scholar 

  39. Sherer M, Boake C, Levin E, et al.: Characteristics of impaired awareness after traumatic brain injury. J Int Neuropsychol Soc 1998, 4:380–387.

    PubMed  CAS  Google Scholar 

  40. Cavallo MM, Kay T, Ezrachi O: Problems and changes after traumatic brain injury: differing perceptions within and between families. Brain Inj 1992, 6:327–335.

    PubMed  CAS  Google Scholar 

  41. Fordyce DJ, Roueche JR: Changes in perspectives of disability among patients, staff, and relatives during rehabilitation of brain injury. Rehab Psychol 1986, 31:217–229.

    Article  Google Scholar 

  42. Rattok J, Ben-Yishay Y, Lakin P, et al.: Outcome of different treatment mixes in a multidimensional neuropsychological rehabilitation program. Neuropsychology 1992, 6:395–415.

    Article  Google Scholar 

  43. Sherer M, Bergloff P, Levin E, et al.: Impaired awareness and employment outcome after traumatic brain injury. J Head Trauma Rehab 1998, 13:52–61.

    CAS  Google Scholar 

  44. Stuss DT: Disturbance of self-awareness after frontal system damage. In Awareness of Deficit After Brain Injury. Edited by Prigatano GP, Schacter DL. New York: Oxford University Press; 1991:63–83.

    Google Scholar 

  45. Watson RT, Valenstein E, Heilman KM: Thalamic neglect: possible role of the medial thalamus and nucleus reticularis in behavior. Arch Neurol 1981, 38:501–506.

    PubMed  CAS  Google Scholar 

  46. Amador XF, Strauss DH, Yale SA, et al.: Assessment of insight in psychosis. Am J Psychiatry 1993, 150:873–879.

    PubMed  CAS  Google Scholar 

  47. Amador XF, Strauss DH: Poor insight in schizophrenia. Psychiatr Q 1992, 64:305–318. This article describes the Scale to Assess Unawareness of Mental Disorder (SUMD), which assesses several different dimensions of unawareness, including awareness of illness in general, awareness of effects of medication, awareness of the social consequences of the illness, awareness of specific symptoms, and attribution of the symptoms. This structured interview is the most frequently used in research with psychiatric patients, and has good reliability.

    Article  Google Scholar 

  48. Cuesta MJ, Peralta V: Lack of insight in schizophrenia. Schizophr Bull 1994, 20:359–366.

    PubMed  CAS  Google Scholar 

  49. David A, Van Os J: Insight and psychotic illness: crosssectional and longitudinal associations. Br J Psychiatry 1995, 167:621–628.

    Article  PubMed  CAS  Google Scholar 

  50. Kemp R, Lambert T: Insight in schizophrenia and its relationship to psychopathology. Schizophr Res 1995, 18:21–28.

    Article  PubMed  CAS  Google Scholar 

  51. Smith TE, Hull JW, Santos L: The relationship between symptoms and insight in schizophrenia: a longitudinal perspective. Schizophr Res 1998, 33:63–67.

    Article  PubMed  CAS  Google Scholar 

  52. Markova IS, Berrios GE: The assessment of insight in clinical psychiatry: a new scale. Acta Psychiatr Scand 1992, 86:159–164.

    PubMed  CAS  Google Scholar 

  53. McEvoy JP, Freter S, Everett G, et al.: Insight and the clinical outcome of schizophrenics. J Nerv Mental Dis 1989, 177:48–51.

    Article  CAS  Google Scholar 

  54. McGlashan T: Does attitude toward psychosis related to outcome? Am J Psychiatry 1981, 138:797–801.

    PubMed  CAS  Google Scholar 

  55. Lysaker P, Bell M: Insight and cognitive impairment in schizophrenia: performance on repeated administrations of the Wisconsin Card Sorting Test. J Nerv Ment Disord 1994, 182:656–660.

    Article  CAS  Google Scholar 

  56. Young DA, Davila R, Scher H: Unawareness of illness and neuropsychological performance in chronic schizophrenia. Schizophr Res 1993, 10:117–124.

    Article  PubMed  CAS  Google Scholar 

  57. McEvoy JP, Freter S, Merritt M, et al.: Insight about psychosis among outpatients with schizophrenia. Hosp Community Psychiatry 1993, 44:883–884.

    PubMed  CAS  Google Scholar 

  58. Buckley PF, Hasan S, Fiedman L, et al.: Insight and schizophrenia. Compr Psychiatry 2001, 42:39–41.

    Article  PubMed  CAS  Google Scholar 

  59. Mohamed S, Fleming S, Penn DL, et al.: Insight in schizophrenia: its relationship to measures of executive functions. J Nerv Ment Disord 1999, 187:525–531.

    Article  CAS  Google Scholar 

  60. Smith TE, Hull JW, Israel LM, et al.: Insight, symptoms, and neurocognition in schizophrenia and schizoaffective disorder. Schizophr Bull 2000, 6:193–200.

    Google Scholar 

  61. Young D, Zakzanis KK, Bailey C, et al.: Further parameters of insight and neuropsychological deficit in schizophrenia and other chronic mental disease. J Nerv Ment Disord 1998, 186:44–50.

    Article  CAS  Google Scholar 

  62. Collins AA, Remington GJ, Coulter K, et al.: Insight, neurocognitive function and symptom clusters in chronic schizophrenia. Schizophr Res 1997, 27:37–44.

    Article  PubMed  CAS  Google Scholar 

  63. Cuesta MJ, Peralta V, Caro F, et al.: Is poor insight in psychotic disorders associated with performance on the Wisconsin Card Sorting Test? Am J Psychiatry 1995, 152:1380–1382.

    PubMed  CAS  Google Scholar 

  64. Kemp R, David A: Psychological predictors of insight and compliance in psychotic patients. Br J Psychiatry 1996, 169:444–450.

    PubMed  CAS  Google Scholar 

  65. McEvoy JP, Hartman M, Gottlieb D, et al.: Common sense, insight, and neuropsychological test performance in schizophrenia patients. Schizophr Bull 1996, 22:635–641.

    PubMed  CAS  Google Scholar 

  66. Flashman LA, McAllister TW, Andreasen NC, et al.: Smaller brain size associated with unawareness in patients with schizophrenia. Am J Psychiatry 2000, 157:1167–1169. This is one of the few studies in the literature that provides evidence of structural correlates associated with unawareness of illness in patients with schizophrenia.

    Article  PubMed  CAS  Google Scholar 

  67. Flashman LA, McAllister TW, Saykin AJ, et al.: Specific frontal lobe regions correlated with unawareness of illness in schizophrenia. J Neuropsychiatry Clin Neurosci 2001, 13:255–257. This study provides the first anatomic evidence of frontal lobe structural relationships in distinct dimensions of awareness deficits in patients with schizophrenia. A significant relationship was found between middle frontal gyrus volume and unawareness of symptoms, and between superior gyrus volume and misattribution of symptoms.

    PubMed  CAS  Google Scholar 

  68. Goldman-Rakic PS, Selemon LD: Functional and anatomical aspects of prefrontal pathology in schizophrenia. Schizophr Bull 1997, 23:437–458.

    PubMed  CAS  Google Scholar 

  69. Goldberg T, Weinberger DR, Berman K: Further evidence for dementia of the prefrontal type in schizophrenia? A controlled study of teaching of the Wisconsin card sorting test. Arch Gen Psychiatry 1987, 44:1008–1014.

    PubMed  CAS  Google Scholar 

  70. Park S, Puschel J, Sauter BH, et al.: Spatial working memory deficits and clinical symptoms in schizophrenia: A 4-month follow-up study. Biol Psychiatry 1999, 46:392–400.

    Article  PubMed  CAS  Google Scholar 

  71. Bertolino A, Esposito G, Callicott JH, et al.: Specific relationship between prefrontal neuronal n-acetylaspartate and activation of the working memory cortical network in schizophrenia. Am J Psychiatry 2000, 157:26–33.

    PubMed  CAS  Google Scholar 

  72. Carter CS, Braver TS, Barch DM, et al.: Anterior cingulate cortex, error detection, and the online monitoring of performance. Science 1998, 280:747–749.

    Article  PubMed  CAS  Google Scholar 

  73. Manoach DS, Press DZ, Thangaraj V, et al.: Schizophrenic subjects activate dorsolateral prefrontal cortex during a working memory task, as measured by fMRI. Biol Psychiatry 1999, 45:1128–1137.

    Article  PubMed  CAS  Google Scholar 

  74. Pini S, Cassano GB, Dell’Osso L, et al.: Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features. Am J Psychiatry 2001, 158:122–125.

    Article  PubMed  CAS  Google Scholar 

  75. Weiler MA, Fleisher MH, McArthur-Campbell D: Insight and symptom change in schizophrenia and other disorders. Schizophr Res 2000, 45:29–36.

    Article  PubMed  CAS  Google Scholar 

  76. Peralta V, Cuesta MJ: Lack of insight in mood disorders. J Affect Disord 1998, 49:55–58.

    Article  PubMed  CAS  Google Scholar 

  77. Ghaemi SN, Boiman E, Goodwin FK: Insight and outcome in bipolar, unipolar, and anxiety disorders. Compr Psychiatry 2000, 41:167–171.

    Article  PubMed  CAS  Google Scholar 

  78. Dell’Osso L, Pini S, Tundo A, et al.: Clinical characteristics of mania, mixed mania, and bipolar depression with psychotic features. Compr Psychiatry 2000, 41:242–247.

    Article  PubMed  CAS  Google Scholar 

  79. Pallanti S, Quercioli L, Pazzagli A, et al.: Awareness of illness and subjective experience of cognitive complaints in patients with bipolar I and bipolar II disorder. Am J Psychiatry 1999, 156:1094–1096.

    PubMed  CAS  Google Scholar 

  80. Ghaemi SN, Stoll AL, Pope HGJ: Lack of insight in bipolar disorder: the acute manic episode. J Nerv Ment Disord 1995, 183:464–467.

    Article  CAS  Google Scholar 

  81. Ghaemi SN, Hebben N, Stoll AL, et al.: Neuropsychological aspects of lack of insight in bipolar disorder: a preliminary study. Psychiatry Res 1996, 65:113–120.

    Article  PubMed  CAS  Google Scholar 

  82. Eisen JL, Rasmussen SA: Obsessive compulsive disorder with psychotic features. J Clin Psychiatry 1993, 54:373–379.

    PubMed  CAS  Google Scholar 

  83. Eisen JL, Rasmussen SA, Phillips KA, et al.: Insight and treatment outcome in obsessive-compulsive disorder. Compr Psychiatry 2001, 42:494–497.

    Article  PubMed  CAS  Google Scholar 

  84. Foa EB, Kozak MJ, Goodman WK, et al.: DSM-IV field trial: obsessive-compulsive disorder. Am J Psychiatry 1995, 152:90–96.

    PubMed  CAS  Google Scholar 

  85. Insel TR, Akiskal HS: Obsessive-compulsive disorder with psychotic features: a phenomenological analysis. Am J Psychiatry 1986, 142:1527–1533.

    Google Scholar 

  86. Lelliott PT, Noshirvani HF, Basoglu M, et al.: Obsessivecompulsive beliefs and treatment outcome. Psychol Med 1988, 18:697–702.

    Article  PubMed  CAS  Google Scholar 

  87. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 4. Washington DC: American Psychiatric Press; 1994.

    Google Scholar 

  88. Eisen JL, Phillips KA, Baer L, et al.: The Brown Assessment of Beliefs Scale: reliability and validity. Am J Psychiatry 1998, 155:102–108.

    PubMed  CAS  Google Scholar 

  89. Takai A, Uematsu M, Ueki H, et al.: Insight and its related factors in chronic schizophrenic patients: a preliminary study. Eur J Psychiatry 1992, 6:159–170. This was the first study to demonstrate a relationship between awareness deficits in patients with schizophrenia and brain anatomy. Using MRI, the authors reported increased ventricle-to-brain ratios in patients with more unawareness.

    Google Scholar 

  90. Morgan KD, Dazzan P, Suckling J, et al.: Neuroanatomic correlates of poor insight: the aesop first-onset psychosis study. Paper presented at the 11th Biennial Winter Workshop on Schizophrenia; Davos, Switzerland. February 24, 2002;

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Flashman, L.A. Disorders of awareness in neuropsychiatric syndromes: An update. Curr Psychiatry Rep 4, 346–353 (2002). https://doi.org/10.1007/s11920-002-0082-x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11920-002-0082-x

Keywords

Navigation