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Metacognitive theory and assessment in dementia: Do we recognize our areas of weakness?

Published online by Cambridge University Press:  16 December 2005

S. COSENTINO  and
Y. STERN
S. COSENTINO
Affiliation:
Cognitive Neuroscience Division of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York Gertrude H. Sergievsky Center, Columbia University Medical Center, New York, New York
Y. STERN
Affiliation:
Cognitive Neuroscience Division of the Taub Institute for Research in Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York Gertrude H. Sergievsky Center, Columbia University Medical Center, New York, New York Department of Neurology, Columbia University Medical Center, New York, New York
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Abstract

Anosognosia, disordered awareness of cognitive and behavioral deficits, is a striking and common symptom of Alzheimer's disease (AD), yet its etiology, clinical correlates, and prognostic value are unclear. Historically, disordered awareness has been a conceptually challenging phenomenon, evidenced by the numerous and diverse theories that aim to explain the manner in which this syndrome arises. We review many of these theories, focusing on the neuroanatomic substrates of awareness, and highlighting the potential roles of critical regions such as the right prefrontal and parietal cortices in enabling self-awareness. We then address methodological limitations such as use of subjective measurement tools that likely contribute to the conceptual ambiguity surrounding anosognosia. We argue that metacognitive techniques used in healthy adults, such as the Feeling of Knowing task, offer models for dissecting awareness into clear and identifiable cognitive components in patients with AD. We critique several studies that have pioneered such tasks in AD, and offer guidelines for future implementation of such methods. A final goal of this review is to advocate for a multidimensional approach to studying metacognitive skills that will facilitate the objective investigation of deficit awareness as it relates to a variety of disease variables such as prognosis, neuropsychological profile, neuropathological distribution, psychiatric symptoms, and clinical course. (JINS, 2005, 11, 910–919.)

Keywords

MetacognitionAnosognosiaDementiaInsightAwarenessAlzheimer's disease
Type
CRITICAL REVIEW
Information
Journal of the International Neuropsychological Society , Volume 11 , Issue 7 , November 2005 , pp. 910 - 919
Copyright
© 2005 The International Neuropsychological Society

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References

REFERENCES

Amador, X.F., Flaum, M., Andreasen, N.C., Strauss, D.H., Yale, S.A., Clark, S.C., & Gorman, J.M. (1994). Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry, 51, 826–836.CrossRefGoogle Scholar
Amador, X.F. & Strauss, D.H. (1990). The Scale to Assess Unawareness of Mental Disorder (SUMD). New York, NY: Columbia University and New York State Psychiatric Institute.
Babinski, M.J. (1914). Contributions a l'etude des troubles mentaux dans l'hemiplegie organique cerebrale (anosognosie). Rev Neurol, 12, 845–847.Google Scholar
Backman, L. & Lipinska, B. (1993). Monitoring of general knowledge: Evidence for preservation in early Alzheimer's disease. Neuropsychologia, 31, 335–345.CrossRefGoogle Scholar
Barrett, A.M., Eslinger, P.J., Ballentine, N.H., & Heilman, K.M. (2005). Unawareness of cognitive deficit (cognitive anosognosia) in probable AD and control subjects. Neurology, 64, 693–699.CrossRefGoogle Scholar
Bisiach, E., Vallar, G., Perani, D., Papagno, C., & Berti, A. (1986). Unawareness of disease following lesions of the right hemisphere: Anosognosia for hemiplegia and anosognosia for hemianopia. Neuropsychologia, 24, 471–482.CrossRefGoogle Scholar
Brand, M., Kalbe, E., Fujiwara, E., Huber, M., & Markowitsch, H.J. (2003). Cognitive estimation in patients with probable Alzheimer's disease and alcoholic Korsakoff patients. Neuropsychologia, 41, 575–584.CrossRefGoogle Scholar
Brown, A.L. (1978). Knowing when, where, and how to remember: A problem of metacognition. Hillsdale, NJ: Erlbaum.
Cotrell, V. & Wild, K. (1999). Longitudinal study of self-imposed driving restrictions and deficit awareness in patients with Alzheimer disease. Alzheimer Dis Assoc Disord, 13, 151–156.CrossRefGoogle Scholar
Critchley, M. (1953). The Parietal Lobes. New York: Hafner Press.
Cutting, J. (1978). Study of anosognosia. Journal of Neurology, Neurosurgery and Psychiatry, 41, 548–555.CrossRefGoogle Scholar
Dalla Barba, G., Parlato, V., Lavarone, A., & Boller, F. (1995). Anosognosia, intrusions and ‘frontal’ functions in Alzheimer's disease and depression. Neuropsychologia, 33, 247–259.CrossRefGoogle Scholar
Danion, J.M., Gokalsing, E., Robert, P., Massin-Krauss, M., & Bacon, E. (2001). Defective relationship between subjective experience and behavior in schizophrenia. Am J Psychiatry, 158, 2064–2066.CrossRefGoogle Scholar
DeBettignies, B.H., Mahurin, R.K., & Pirozzolo, F.J. (1990). Insight for impairment in independent living skills in Alzheimer's disease and multi-infarct dementia. J Clin Exp Neuropsychol, 12, 355–363.CrossRefGoogle Scholar
Derouesne, C., Thibault, S., Lagha-Pierucci, S., Baudouin-Madec, V., Ancri, D., Lacomblez, L. (1999). Decreased awareness of cognitive deficits inpatients with mild dementia of the Alzheimer type. International Journal of Geriatric Psychiatry, 14, 1019–1030.3.0.CO;2-F>CrossRefGoogle Scholar
Duke, L.M., Seltzer, B., Seltzer, J.E., & Vasterling, J.J. (2002). Cognitive components of deficit awareness in Alzheimer's disease. Neuropsychology, 16, 359–369.CrossRefGoogle Scholar
Feher, E.P., Larrabee, G.J., Sudilovsky, A., & Crook, T.H., 3rd. (1994). Memory self-report in Alzheimer's disease and in age-associated memory impairment. J Geriatr Psychiatry Neurol, 7, 58–65.CrossRefGoogle Scholar
Feinberg, T.E. (2001). Altered egos: How the brain creates the self. New York: Oxford University Press.
Feinberg, T.E., Eaton, L.A., Roane, D.M., & Giacino, J.T. (1999). Multiple fregoli delusions after traumatic brain injury. Cortex, 35, 373–387.CrossRefGoogle Scholar
Fernandez-Duque, D., Baird, J.A., & Posner, M.I. (2000). Executive attention and metacognitive regulation. Conscious Cogn, 9, 288–307.CrossRefGoogle Scholar
Flavell, J.H. & Wellman, H.M. (1977). Perspectives on the development of memory and cognition. Hillsdale, NJ: Erlbaum.
Geschwind, N. (1965). Disconnexion syndromes in animals and man. Brain, 88, 237–294.CrossRefGoogle Scholar
Greene, J.D., Baddeley, A.D., & Hodges, J.R. (1996). Analysis of the episodic memory deficit in early Alzheimer's disease: Evidence from the doors and people test. Neuropsychologia, 34, 537–551.CrossRefGoogle Scholar
Grossman, M. (2000). Frontotemporal dementia: A review. Journal of the International Neuropsychological Society, 8, 566–583.Google Scholar
Hart, J.T. (1965). Memory and the feeling of knowing experience. Journal of Educational Psychology, 56, 208–216.CrossRefGoogle Scholar
Head, H. & Holmes, G. (1911). Sensory disturbances from cerebral lesions. Brain, 34, 102–254.CrossRefGoogle Scholar
Heilman, K.M. (1991). Anosognosia: Possible Neuropsychological Mechanisms. In G.P. Prigatano & D.L. Schacter (Eds.), Awareness of Deficit After Brain Injury (pp. 53–62). New York: Oxford University Press.
Heilman, K.M., Watson, R.T., & Valenstein, E. (1993). Neglect and related disorders. In K.M. Heilman, & E. Valenstein (Eds.), Clinical Neuropsychology (3rd ed., pp. 279–336). New York, NY: Oxford University Press.
Kaszniak, A.W. & Zak, M. (1996). On the neuropsychology of metamemory: Contributions from the study of amnesia and dementia. Learning and Individual Differences, 8, 355–381.CrossRefGoogle Scholar
Kikyo, H., Ohki, K., & Miyashita, Y. (2002). Neural correlates for feeling-of-knowing: An fMRI parametric analysis. Neuron, 36(1), 177–186.CrossRefGoogle Scholar
Klatzky, R.L. & Erdelyi, M.H. (1985). The response criterion problem in tests of hypnosis and memory. International Journal of Clinical and Experimental Hypnosis, 33, 246–257.CrossRefGoogle Scholar
Koren, D., Seidman, L.J., Poyurovsky, M., Goldsmith, M., Viksman, P., Zichel, S., & Klein, E. (2004). The neuropsychological basis of insight in first-episode schizophrenia: A pilot metacognitive study. Schizophr Res, 70, 195–202.CrossRefGoogle Scholar
Kotler-Cope, S. & Camp, C.J. (1995). Anosognosia in Alzheimer disease. Alzheimer Dis Assoc Disord, 9, 52–56.CrossRefGoogle Scholar
Leonesio, R.J. & Nelson, T.O. (1990). Do different metamemory judgments tap the same underlying aspects of memory? J Exp Psychol Learn Mem Cogn, 16, 464–467.Google Scholar
Levine, D.N. (1990). Unawareness of visual and sensorimotor defects: A hypothesis. Brain Cogn, 13, 233–281.CrossRefGoogle Scholar
Levine, D.N., Calvanio, R., & Rinn, W.E. (1991). The pathogenesis of anosognosia for hemiplegia. Neurology, 41, 1770–1781.CrossRefGoogle Scholar
Lopez, O.L., Becker, J.T., Somsak, D., Dew, M.A., & DeKosky, S.T. (1994). Awareness of cognitive deficits and anosognosia in probable Alzheimer's disease. Eur Neurol, 34, 277–282.CrossRefGoogle Scholar
Loring, D.W. (1999). INS Dictionary of Neuropsychology. New York, NY: Oxford University Press.
Mangone, C.A., Hier, D.B., Gorelick, P.B., Ganellen, R.J., Langenberg, P., Boarman, R., & Dollear, W.C. (1991). Impaired insight in Alzheimer's disease. J Geriatr Psychiatry Neurol, 4, 189–193.CrossRefGoogle Scholar
Marcel, A.J., Tegner, R., & Nimmo-Smith, I. (2004). Anosognosia for plegia: Specificity, extension, partiality and disunity of bodily unawareness. Cortex, 40, 19–40.CrossRefGoogle Scholar
Mark, V.W., Kooistra, C.A., & Heilman, K.M. (1988). Hemispatial neglect affected by non-neglected stimuli. Neurology, 38, 1207–1211.CrossRefGoogle Scholar
Marshall, G.A., Kaufer, D.I., Lopez, O.L., Rao, G.R., Hamilton, R.L., & DeKosky, S.T. (2004). Right prosubiculum amyloid plaque density correlates with anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry, 75, 1396–1400.CrossRefGoogle Scholar
McDaniel, K.D., Edland, S.D., & Heyman, A. (1995). Relationship between level of insight and severity of dementia in Alzheimer disease. CERAD Clinical Investigators. Consortium to Estabish a Registry for Alzheimer's Disease. Alzheimer Dis Assoc Disord, 9, 101–104.Google Scholar
McGlynn, S.M. & Schacter, D.L. (1989). Unawareness of deficits in neuropsychological syndromes. J Clin Exp Neuropsychol, 11, 143–205.CrossRefGoogle Scholar
Meador, K.J., Loring, D.W., Feinberg, T.E., Lee, G.P., & Nichols, M.E. (2000). Anosognosia and asomatognosia during intracarotid amobarbital inactivation. Neurology, 55, 816–820.CrossRefGoogle Scholar
Mesulam, M.M. (1985). Principles of Behavioral Neurology. Philadelphia: Davis.
Metcalfe, J. Shimamura, A.P. (Ed.). (1994). Metacognition: Knowing about Knowing. London: The MIT Press.
Michon, A., Deweer, B., Pillon, B., Agid, Y., & Dubois, B. (1994). Relation of anosognosia to frontal lobe dysfunction in Alzheimer's disease. J Neurol Neurosurg Psychiatry, 57, 805–809.CrossRefGoogle Scholar
Migliorelli, R., Petracca, G., Teson, A., Sabe, L., Leiguarda, R., & Starkstein, S.E. (1995a). Neuropsychiatric and neuropsychological correlates of delusions in Alzheimer's disease. Psychol Med, 25, 505–513.Google Scholar
Migliorelli, R., Teson, A., Sabe, L., Petracca, G., Petracchi, M., Leiguarda, R., & Starkstein, S.E. (1995b). Anosognosia in Alzheimer's disease: A study of associated factors. J Neuropsychiatry Clin Neurosci, 7, 338–344.Google Scholar
Miller, B.L., Chang, L., Mena, I., Boone, K., & Lesser, I.M. (1993). Progressive right frontotemporal degeneration: Clinical, neuropsychological and SPECT characteristics. Dementia, 4, 204–213.CrossRefGoogle Scholar
Moulin, C.J., Perfect, T.J., & Jones, R.W. (2000a). The effects of repetition on allocation of study time and judgements of learning in Alzheimer's disease. Neuropsychologia, 38, 748–756.Google Scholar
Moulin, C.J., Perfect, T.J., & Jones, R.W. (2000b). Evidence for intact memory monitoring in Alzheimer's disease: Metamemory sensitivity at encoding. Neuropsychologia, 38, 1242–1250.Google Scholar
Neary, D., Snowden, J.S., Bowen, D.M., Sims, N.R., Mann, D.M., Benton, J.S., Northen, B., Yates, P.O., & Davison, A.N. (1986). Neuropsychological syndromes in presenile dementia due to cerebral atrophy. J Neurol Neurosurg Psychiatry, 49, 163–174.CrossRefGoogle Scholar
Nelson, H.E. (1976). A modified card sorting test sensitive to frontal lobe defects. Cortex, 12, 313–324.CrossRefGoogle Scholar
Nelson, T. & Narens, L. (1990). Metamemory: A theoretical framework and new findings. Psychology of Learning and Motivation, 26, 125–322.CrossRefGoogle Scholar
Nelson, T.O., Gerler, D., & Narens, L. (1984). Accuracy of feeling-of-knowing judgments for predicting perceptual identification and relearning. J Exp Psychol Gen, 113, 282–300.CrossRefGoogle Scholar
Nelson, T.O. & Narens, L. (1980). Norms of 300 general information questions: Accuracy of recall and feeling-of-knowing ratings. Journal of verbal learning and verbal behavior, 19, 338–368.CrossRefGoogle Scholar
Nelson, T.O. & Narens, L. (1984). A comparison of current measures of the accuracy of feeling-of-knowing predictions. Psychological Bulletin, 95, 109–133.CrossRefGoogle Scholar
Ott, B.R., Lafleche, G., Whelihan, W.M., Buongiorno, G.W., Albert, M.S., & Fogel, B.S. (1996). Impaired awareness of deficits in Alzheimer disease. Alzheimer Dis Assoc Disord, 10, 68–76.CrossRefGoogle Scholar
Pappas, B.A., Sunderland, T., Weingartner, H.M., Vitello, B., Martinson, H., & Putnam, K. (1992). Alzheimer's disease and feeling-of-knowing for knowledge and episodic memory. Journal of Gerontology: Psychological Sciences, 47, 159–164.CrossRefGoogle Scholar
Petersen, R.C. (2004). Mild cognitive impairment as a diagnostic entity. J Intern Med, 256, 183–194.CrossRefGoogle Scholar
Pia, L., Neppi-Modona, M., Ricci, R., & Berti, A. (2004). The anatomy of anosognosia for hemiplegia: A meta-analysis. Cortex, 40, 367–377.CrossRefGoogle Scholar
Platek, S.M., Keenan, J.P., Gallup, G.G., Jr., & Mohamed, F.B. (2004). Where am I? The neurological correlates of self and other. Brain Res Cogn Brain Res, 19, 114–122.CrossRefGoogle Scholar
Prigatano, G.P. (1991). Disturbances in self-awareness after traumatic brain injury. In G.P. Prigatano & D.L. Schacter (Eds.), Awareness of Deficit After Brain Injury (pp. 111–126). New York: Oxford University Press.
Prigatano, G.P. & Schacter, D.L. (1991). Awareness of Deficit after Brain Injury. New York: Oxford University Press.
Rainville, C., Giroire, J.M., Periot, M., Cuny, E., & Mazaux, J.M. (2003). The impact of right subcortical lesions on executive functions and spatio-cognitive abilities: A case study. Neurocase, 9, 356–367.CrossRefGoogle Scholar
Ramachandran, V.S. (1995). Anosognosia in parietal lobe syndrome. Conscious Cogn, 4, 22–51.CrossRefGoogle Scholar
Reed, B.R., Jagust, W.J., & Coulter, L. (1993). Anosognosia in Alzheimer's disease: Relationships to depression, cognitive function, and cerebral perfusion. J Clin Exp Neuropsychol, 15, 231–244.CrossRefGoogle Scholar
Saravanan, B., Jacob, K.S., Prince, M., Bhugra, D., & David, A.S. (2004). Culture and insight revisited. Br J Psychiatry, 184, 107–109.CrossRefGoogle Scholar
Schacter, D.L. (1983). Feeling-of-knowing in episodic memory. Journal of Experimental Psychology: Learning, Memory, and Cognition, 9, 39–54.Google Scholar
Schacter, D.L. (1990). Toward a Cognitive Neuropsychology of Awareness: Implicit Knowledge and Anosognosia. Journal of Clinical and Experimental Neuropsychology, 12, 155–178.CrossRefGoogle Scholar
Schnyer, D.M., Verfaellie, M., Alexander, M.P., LaFleche, G., Nicholls, L., & Kaszniak, A.W. (2004). A role for right medial prefontal cortex in accurate feeling-of-knowing judgements: Evidence from patients with lesions to frontal cortex. Neuropsychologia, 42, 957–966.CrossRefGoogle Scholar
Sevush, S. & Leve, N. (1993). Denial of memory deficit in Alzheimer's disease. Am J Psychiatry, 150, 748–751.Google Scholar
Shimamura, A.P. (2000). Toward a cognitive neuroscience of metacognition. Conscious Cogn, 9, 313–323 (Discussion 324–316).CrossRefGoogle Scholar
Shimamura, A.P. & Squire, L.R. (1986). Memory and metamemory: A study of the feeling-of-knowing phenomenon in amnesic patients. J Exp Psychol Learn Mem Cogn, 12, 452–460.CrossRefGoogle Scholar
Smith, C.A., Henderson, V.W., McCleary, C.A., Murdock, G.A., & Buckwalter, J.G. (2000). Anosognosia and Alzheimer's disease: The role of depressive symptoms in mediating impaired insight. J Clin Exp Neuropsychol, 22, 437–444.CrossRefGoogle Scholar
Souchay, C., Isingrini, M., Clarys, D., Taconnat, L., & Eustache, F. (2004). Executive functioning and judgment-of-learning versus feeling-of-knowing in older adults. Exp Aging Res, 30, 47–62.CrossRefGoogle Scholar
Starkstein, S.E., Chemerinski, E., Sabe, L., Kuzis, G., Petracca, G., Teson, A., & Leiguarda, R. (1997). Prospective longitudinal study of depression and anosognosia in Alzheimer's disease. Br J Psychiatry, 171, 47–52.CrossRefGoogle Scholar
Starkstein, S.E., Sabe, L., Chemerinski, E., Jason, L., & Leiguarda, R. (1996). Two domains of anosognosia in Alzheimer's disease. J Neurol Neurosurg Psychiatry, 61, 485–490.CrossRefGoogle Scholar
Starkstein, S.E., Vazquez, S., Migliorelli, R., Teson, A., Sabe, L., & Leiguarda, R. (1995). A single-photon emission computed tomographic study of anosognosia in Alzheimer's disease. Arch Neurol, 52, 415–420.CrossRefGoogle Scholar
Stuss, D.T., Gow, C.A., & Hetherington, C.R. (1992). “No longer Gage”: Frontal lobe dysfunction and emotional changes. J Consult Clin Psychol, 60, 349–359.CrossRefGoogle Scholar
Sussman, L.K. (Ed.). (2004). The role of culture in definitions, interpretations, and management of illness. Mahwah, NJ: Lawrence Erlbaum Associates.
Tiedens, L.Z. & Linton, S. (2001a). Judgment under emotional certainty and uncertainty: The effects of specific emotions on information processing. Journal of Personality and Social Psychology, 81, 973–988.Google Scholar
Tiedens, L.Z. & Linton, S. (2001b). Judgment under emotional certainty and uncertainty: The effects of specific emotions on information processing. J Pers Soc Psychol, 81, 973–988.Google Scholar
Ullman, M., Ashenhurst, E.M., Hurwitz, L.J., & Gruen, A. (1960). Motivational and structural factors in the denial of hemiplegia. Arch Neurol, 3, 306–318.CrossRefGoogle Scholar
Venneri, A. & Shanks, M.F. (2004). Belief and awareness: Reflections on a case of persistent anosognosia. Neuropsychologia, 42, 230–238.CrossRefGoogle Scholar
Verhey, F.R.J., Rozendaal, N., Ponds, R.W.H.M., & Jolles, J. (1993). Dementia, awareness, and depression. International Journal of Geriatric Psychiatry, 8, 851–856.CrossRefGoogle Scholar
Vilkki, J., Servo, A., & Surma-aho, O. (1998). Word list learning and prediction of recall after frontal lobe lesions. Neuropsychology, 12, 268–277.CrossRefGoogle Scholar
Vogel, A., Hasselbalch, S.G., Gade, A., Ziebell, M., & Waldemar, G. (2005). Cognitive and functional neuroimaging correlate for anosognosia in mild cognitive impairment and Alzheimer's disease. Int J Geriatr Psychiatry, 20, 238–246.CrossRefGoogle Scholar
Vogel, A., Stokholm, J., Gade, A., Andersen, B.B., Hejl, A.M., & Waldemar, G. (2004). Awareness of deficits in mild cognitive impairment and Alzheimer's disease: Do MCI patients have impaired insight? Dement Geriatr Cogn Disord, 17, 181–187.Google Scholar
von Monakow, A. (1885). Experimentelle and pathologischanatomisch untersuchungen uber die Beziehungen der sogennanten Sehspare zu den infracorticalen Opticuscentren und zum Nervus opticus. Archiv fur Psychiatrie, 16, 151–199.CrossRefGoogle Scholar
Vuilleumier, P. (2000). Anosognosia. Cambridge, UK: Cambridge University Press.
Vuilleumier, P. (2004). Anosognosia: The neurology of beliefs and uncertainties. Cortex, 40, 9–17.CrossRefGoogle Scholar
Weinstein, E. & Kahn, R. (1955). Denial of Illness. Springfield, Illinois: Charles C. Thomas.
Weinstein, E.A. & Kahn, R.L. (1953). Personality factors in denial of illness. AMA Arch Neurol Psychiatry, 69, 355–367.CrossRefGoogle Scholar
Welsh, K., Butters, N., Hughes, J., Mohs, R., & Heyman, A. (1991). Detection of abnormal memory decline in mild cases of Alzheimer's disease using CERAD neuropsychological measures. Arch Neurol, 48, 278–281.CrossRefGoogle Scholar
White, R., Bebbington, P., Pearson, J., Johnson, S., & Ellis, D. (2000). The social context of insight in schizophrenia. Soc Psychiatry Psychiatr Epidemiol, 35, 500–507.CrossRefGoogle Scholar
Zanetti, O., Vallotti, B., Frisoni, G.B., Geroldi, C., Bianchetti, A., Pasqualetti, P., & Trabucchi, M. (1999). Insight in dementia: When does it occur? Evidence for a nonlinear relationship between insight and cognitive status. Journal of Gerontology: Psychological Sciences, 54, 100–106.CrossRefGoogle Scholar