Errol Morris on Anosognosia

Here are some bits from a 5-part series that Errol Morris has written on anosognosia:

Part 1:

An anosognosic patient who is paralyzed simply does not know that he is paralyzed. If you put a pencil in front of them and ask them to pick up the pencil in front of their left hand they won’t do it. And you ask them why, and they’ll say, “Well, I’m tired,” or “I don’t need a pencil.” They literally aren’t alerted to their own paralysis. There is some monitoring system on the right side of the brain that has been damaged, as well as the damage that’s related to the paralysis on the left side. There is also something similar called “hemispatial neglect.” It has to do with a kind of brain damage where people literally cannot see or they can’t pay attention to one side of their environment. If they’re men, they literally only shave one half of their face. And they’re not aware about the other half. If you put food in front of them, they’ll eat half of what’s on the plate and then complain that there’s too little food. You could think of the Dunning-Kruger Effect as a psychological version of this physiological problem. If you have, for lack of a better term, damage to your expertise or imperfection in your knowledge or skill, you’re left literally not knowing that you have that damage. It was an analogy for us.

Part 2:

June 11, 1914. In a brief communication presented to the Neurological Society of Paris, Joseph Babinski (1857-1932), a prominent French-Polish neurologist, former student of Charcot and contemporary of Freud, described two patients with “left severe hemiplegia” – a complete paralysis of the left side of the body – left side of the face, left side of the trunk, left leg, left foot. Plus, an extraordinary detail. These patients didn’t know they were paralyzed. To describe their condition, Babinski coined the term anosognosia – taken from the Greek agnosia, lack of knowledge, and nosos, disease.

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There were many unanswered questions in Babinski’s original paper. Did the anosognosic patient have absolutely no knowledge or some limited knowledge of her left-side paralysis? Was there a blocked pathway in the brain? Was the anosognosia an organic (or somatic) disease? Or a derangement of thought? Was she in some sort of trance? Babinski also noted that many of his anosognosic patients developed odd rationalizations. When he asked them to move their left (paralyzed) arms, they would decline to do so, offering a myriad of implausible excuses. (Furthermore, not all of his patients with left-side paralysis were clueless about their condition. Some patients had knowledge of their paralysis but were oddly indifferent to it. For these patients, Babinski coined the term anosodiaphoria, or indifference to paralysis.

Part 3:

Discusses the stroke of President Woodrow Wilson in 1919 and whether he had anosognosia and whether this illness caused the US to not ratify the treaty for the League of Nations.

Part 4:

V.S. Ramachandran has written about anosognosia in a number of journal articles and in his extraordinary book with Sandra Blakeslee, “Phantoms in the Brain.” Ramachandran rarely settles for the status quo. If there is something unexplained, he pursues it, trying to provide an answer, if not the answer. He has made a number of spectacular discoveries, most famous among them his innovative use of mirror-boxes to treat phantom limb syndrome. Rather than devise complex experiments, he prefers simple intuitive questions and answers. His work on anosognosia is a perfect example.

Ramachandran was taken in by a question that haunts Babinski’s original work on anosognosia — the question of whether the anosognosic knows (on some level) about the paralysis. What is going on in an anosognosic brain? (Babinski’s original question: Is it real?) Almost any deficit can be explained as volitional. How do you know that an anosognosic patient is really in denial, or oblivious, or indifferent to his/her paralysis? How do you know that the patient is not feigning illness? This was a critical question during World War I, when neurologists had to deal with a flood of injured soldiers and had to discriminate between the truly damaged and those just malingering.

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V.S. RAMACHANDRAN: Well, you can have anosognosia for Wernicke’s aphasia [a neurological disorder that prevents comprehension or production of speech] or you can have it for amnesia. Patients that are amnesic don’t know they are amnesic. So, it has a much wider, broader usage. Although it was originally discovered in the context of hemiplegia by Babinski and is most frequently used in that context, the word has a broader meaning. Wernicke’s aphasiacs are completely lacking in language comprehension and seem oblivious to it because [although] they smile, or they nod to whatever you say, they don’t understand a word of what you’re saying. They have anosognosia for their lack of comprehension of language. It’s really spooky to see them. Here’s somebody producing gibberish, and they don’t know they’re producing gibberish.

Part 5:

DAVID DUNNING: Here’s a thought. The road to self-insight really runs through other people. So it really depends on what sort of feedback you are getting. Is the world telling you good things? Is the world rewarding you in a way that you would expect a competent person to be rewarded? If you watch other people, you often find there are different ways to do things; there are better ways to do things. I’m not as good as I thought I was, but I have something to work on. Now, the sad part about that is — there’s been a replication of this with medical students — people at the bottom, if you show them what other people do, they don’t get it. They don’t realize that what those other people are doing is superior to what they’re doing. And that’s the troubling thing. So for people at the bottom, that social comparison information is a wonderful piece of information, but they may not be in a position to take advantage of it like other people.

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For years, I have had my own version of the story of the expulsion from the Garden of Eden. In my version, God appears before Adam and Eve, and tells them that they have disobeyed Him. He admonishes them, and they will have to leave immediately. Everything will be completely grotesque, grim, ghastly and gruesome outside of Eden. God spares them no detail. Adam and Eve, both crestfallen and fearful, prepare to leave, but God, feeling perhaps a little guilty for the severity of his decision, looks at them and says, “Yes, things will be bad out there, but I’m giving you self-deception so you’ll never notice.”

The above series of articles provokes a lot of questions and thoughts. I got me thinking about my mother...

My mother died of a brain tumour. The effect of the tumour was poor balance and problems with manipulating things with her left hand. After the surgery to remove the tumour, she was left with "left neglect", the anosognosia described in the above articles. I was horrified that the surgeon whose "treatment" worsened the condition and led to her death within 3 weeks never too any responsibility for his clumsy surgery. I was further horrified by the poor treatment my mother got in hospital. My family is only 2 generations removed from farming where you cared for the sick and dying at home. My mother would have gotten superior help in his last three weeks by being at home. But he was a "medical" system that condemns people to die in the brutal environment of a hospital where paid workers show minimal regard for their charges. For my mother this evidenced itself in the following ways:

• They persisted in putting the service call button on her left side, but with left neglect she was completely unaware of its presence, so she was effectively abandoned until family noticed the mistake and put it on the right or until a staff change and remaking of the bed moved it to the right side. The worst incident resulting from this "oversight" by the nursing staff was when she was left on a hard metal bedpan for 4 hours because she couldn't find the service bell and her voice was too weak to get the attention of staff.


• The orderlies were extremely clumsy moving her to/from the bed. She was limited in how she could help them because of her left paralysis. They invariably stepped on her bare feet with their shoes hurting her and risking broken bones. She was fragile and at their mercy and pointing this out to staff did nothing to prevent its recurring.


• Food was placed in front of her and none of the staff showed any awareness that her left neglect meant she would not attend to any food on the left. So they left her to pick at the food on the right. Worse, they gave her utensils wrapped in plastic that are hard enough to get at whith two hands. In short, her meals were frustrating. She was already well underweight. She died withing three weeks in large part because of malnourishment. When I pointed out the problems with food to the hospital they pretended to show concern, but they didn't ask any questions or follow up in any way that would indicate that they truly wanted to learn from mistakes. One incident sticks in my mind: she was rushed from a "rehabilitation" hospital to emergency suffering from a severe infection. When we arrived, waited for emergency care to be complete, and accompanied her to her hospital room, I requested food for her. The hospital said they couldn't provide anything because the cafeteria was closed and the dietician was not available. I kept insisting and they finally brought her a "snack". She was a severely underweight woman and was hungry and only got this "food" under protest from the hospital despite the fact that she had missed her supper because of the emergency room care.


• I noticed that the hospital did have signs put on rooms & beds where patients had a risk of falling. This was to call the attention of the nursing staff to this condition and the need for extra care. My request for a similar sign to call attention to "left neglect" was ignored by the hospital. Consequently the level of care was haphazard at best. Only those staff who took the time to understand my mother's condition even had a possibility of taking appropriate care. This kind of neglect was endemic to the hospital situation. I spent months assuring the hospital that I was not interested in suing over my mother's death. I just wanted to make them aware of her problems and their inadequacies in caring for her. They showed no more than "superficial" concern, i.e. they acknowledged my letters and "assured" me that their procedures ensured that patients got the best possible care. They weren't interested in hearing about any failings on their part. They weren't interested in improving their practices.