- Email: [email protected]
Disorientation states and psychiatry
Disorientation States and Psychiatry G.
E. Berrios
T
EMPOROSPATIAL Disorientation has been regarded since the late 19th century as the tangible expression of clouding of consciousness and hence as a clinical indication of organic mental disorder.’ At the same time disorientation-like states have been described accompanying some forms of acute schizophrenia,’ of mania,3 of depression4 of puerperal psychoses,‘.‘.’ and of fugue states. 8.9 In addition, the same term is also used to refer to specific orientation failures associated with cerebra-cortical syndromes.“‘~“~“~‘3~‘4~‘l.‘i Because it is not clear whether the various mental states mentioned are connected two views have developed. The unitary hypothesis states that all orientation failures result from perturbation of a common mechanism;‘h.‘7 the multimodal view on the other hand considers psychiatric and neurological disorientation as separate states. A variant of this view suggests that even temporal and spatial forms of disorientation may be potentially disociable.‘x.‘y.“’ Disagreement has arisen from many sources. Orientation failures are elusive clincial states; it is unclear whether clinical presentation and aetiology are related, for example whether delirious disorientation is related, say, to parietal lobe dysfunction; it is equally obscure whether orientation for time, space, and person depend upon different psychological and neural systems and whether this is the explanation for the clinical fact that orientation in some dimensions may be more resistant to breakdown than orientation in others.‘” Since standard techniques to elicit the phenomenon are not yet available research results are hardly comparable. As a consequence there is uncertainty as to the clinical value of this symptom. Disorientation may, after all, turn out to be only a crude index of cognitive failure. This paper organizes the field from the historical, clinical and conceptual viewpoints and suggests a model for the analysis of global disorientation in relation to delirium and the functional psychoses. It does not include however the so-called analysis of “chrono and space agnosias” as it takes the view that they constitute separate clinical phenomena. TERMS AND CONCEPTS Disorientation is used both as a descriptive and as an explanatory concept. Like the terms hallucination or delusion, it refers to an ongoing mental state: but unlike them it identifies a failure in “knowing that” (verbal orientation) and “knowing what” (behavioural orientation).” Orientation entails a fine
Depurtment of Psychiatry, Uni\lersity of Cambridge. E. Berrios, MA; D.Phil. Sci. (Oxon): MD: FRCPsych..
From G.
Department Address
of Psychiutry. reprint
Lecturer
and
Hospital
(Level
0
requests 4). Hills
of Cambridge.
to G. E. Berrios,
Consultant,
1982 by Grune
Comprehensive
University Department Road,
& Stratton.
Psychiatry,
MA:
Cambridge. Inc.
Vol.
23,
Cambridge.
D.Phil.
of Psychiatp.
Cambridge, Uni\,rrsity
and Con.crc~ta~~t.
England
Sci. (Oxon): Uniwrsity
England
Lecturer MD:
FRCPsych..
of‘ Cumhridge.
lJni\,er.\it>
Addenbrooke’c
England
OOlO-44041821230510010$1.00I0
No.
5
(SeptJOct.1,
1982
479
G. E. BERRIOS
480
tuning between the subject and the internal representation he forms of the corresponding public reference system.” Since the latter changes the subject must be able to update his internal map. Breakdowns in orientation may therefore result from an inability to: (1) perceive the relevant reference system; (2) utilize the information thus obtained in the updating of the internal map; (3) recall the updated map; (4) carry out a match-mismatch operation; (5) act upon detected mismatching. Occasionally failures in orientation may also result from interference or confusion caused by the presence of a new reference system (e.g. delusional) which is privately generated by the subject. In this paper “Orientation failure” will be used as a general term to refer to any clinical situation in which a dislocation can be observed between the orientation behaviour of the subject (whether verbal or nonverbal) and the consensual reference system. “False orientation” will name a situation when the failure results from reorientation in relation to a pathological private reference system. “Double orientation” will describe the clinical situation in which the subject may be orientated, simultaneously or alternatively, in relation to a private and public reference system. “Disorientation” (proper) will refer to an orientation failure in which the subject has lost all ability to orientate himself; this may result from cognitive impairment or unavailability of reference systems or both. HISTORICAL
ASPECTS
The English word “orientation” derives from the French “orienter”23 and was first used as a scientific term in astronomy.24 Mott referred as “imperfect orientation” one of the psychological disturbances caused by cerebral arteriosclerosis. Disorientation, as a symptom, did not escape observation in earlier times and was occasionally described in association with acute brain syndromes,26v27 stupor,28 transient memory disturbance29s30 and reduction in mental function.3’ By the end of the century and under the influence of the localizationist drive mental orientation began to be considered as an independent function.32 For example its failures were subdivided by Wernicke into autopsychic (personal identity); somatopsychic (corporality), and allopsychic (time and place).33 Janet used the term “feeling of disorientation” to describe the experience of loss of appreciation of the spatial relationship that objects hold with one another,34 and Konig to characterize the confusion observed in some cases of Parkinson’s disease.3s Jaspers identified four types of disorientation: amnesic, delusional, apathetic and clouded.36 Bleuler drew attention to the phenomenon of psychotic “double orientation”.37 These early views have influenced current clinical practice; for example the orientation failure observed in delirium is considered as resulting from a temporary disturbance of consciousness;7,38.39 that of Korsakoff’s states as stemming from a failure of memory4’ and that of the functional psychoses as secondary to delusional beliefs.37s4’ FAILURES
IN TIME ORIENTATION
The complex issues involved in the definition and perception of time have encouraged speculation both at a genera142,43and at a clinical leve1.44,45Time
481
DISORIENTATION STATES
disorientation has been described in association with most psychiatric conditions;4” this is right if a wide definition of the symptom is utilized; for example patients experiencing distortions in their feelings of duration may be regarded as disorientated in a loose sense. On the other hand, the use of a narrow definition, for example one based upon objective testing of the patient’s perception of time, yields a lower incidence of orientation failures. The diagnostic value of these definitions has not yet been properly assessed. Time orientation depends upon the monitoring of three time reckoning systems. The offical time (OT) reference system,47 as kept by public time-markers. which the individual perceives as a continuous flow but conceptualizes as a nest of subunits (year, month and date); secondly “cued time” (CT) (e.g. awareness of time of day or of season of year) whose adequate monitoring relies on the correct recognition of cues;” these can be external (e.g. climate, social rituals) or internal (proprioceptive sensations). The third time reckoning mechanism refers to the individual’s subjective experience of duration (i.e. “personal time”).48 Since probably different cognitive functions are involved in the monitoring of these three systems independent breakdown of each may occur in response to different noxae. Thus, clinical observation shows that official and cued time disorientation are often associated with organic disorder,49 while distortions in the perception of personal time are common in relation to functional disorders such as severe anxiety.5” obsessional states,46 depression’ and schizophrenia.4h.S’.” Temporal orientation is believed to be more vulnerable than space or personal orientation.lh.‘x.‘” Verbal orientation is tested by asking standard questions which assess synchronization to different reckoning systems;‘4 incorrect answers beyond certain limits are considered as pathological but cut off points vary from clinician to clinician. Thus Benton et a1.49 have shown that clinical judgement alone results in an unacceptable number of false negatives. At the beginning of the century Bouchard”; used the testing strategy of asking the subject to “produce”, (by tapping or pacemaking) or to “reproduce” time, i.e. to judge the duration of a given unit of official time. The relevance of this measurement to time disorientation has been called into question.“‘.” Temporal Disorientation
in the Orgunic Mental States
States of altered cognition are often associated with temporal disorientation. Delirium’7~“8and confusional statess9.60 are as a rule accompanied by fluctuating temporal disorientation and so are the dementia1 states;6’.h’ likewise between 25 and 39 per cent of brain damaged subjects exhibit a form of time disorientation63,h4 and so do patients with diffuse cortical disease.6s In these cases the parsimonious explanation is that time disorientation may result from memory, attention or perceptual failure. On occasions, however, time disorientation has been described as an isolated symptom and this raises the issue of whether it depends upon dysfunction of a particular neural network. For example Ellen and Powell’” found that the “scallop” response profile in rats, i.e. the distribution of responding during fixed interval reinforcement is affected by lesions in the zona incerta. Likewise
G. E. BERRIOS
482
in humans it has been suggested by Efron6’ that “there is a fundamental mechanism or process related to the requirement of “time-1abelling” of input or output signals which is located in the dominant temporal lobe” dysfunction of which, would explain the disturbance of subjective time sense seen in temporal lobe epilepsy. Spiegel et a1.68 have also described impairment of temporal orientation in schizophrenic patients (without disorientation in space) after lesions in the dorsomedial thalamic nucleus; patients were confused regarding date, season of the year, and time of day and mis-stated their age and that of their children. This defect, referred to as “chronotaraxis”, was however transitory and occurred independently from clouding of consciouness. Some of these patients however also exhibited memory defect which could explain their time disorientation. The same cautionary note must apply to the so-called Time Agnosia syndrome69 described in 7 male patients with traumatic, alcoholic or vascular brain disturbance who after emerging from unconsciousness showed amnesia, confusion, time disorientation and difficulty in estimating time intervals; in contrast their appreciation of rhythm was satisfactory. Bowman and Grtinbaum’” have described the symptom of “chronognosie” resulting from a viral infection; this patient however also exhibited cognitive dysfunction. Critchley” has stated that “Pure temporal disorientation, that is, occurring independently of spatial disorders, is a rare phenomenon” and listed a number of clinical situations in which a failure of “Zeitauffassung” (Time apperception) can be assumed. Amongst these he includes inability to judge the passage of time; difficulty in estimating the approximate hour of the day, gross disorientation in time and the feeling of time rushing past. Time Disorientation
in the Affective
Disorders
An early paper by Lewis included examples of disturbances in personal time experience in a number of psychiatric disorders.46 He concluded that a disorder of time-consciousness “may be found almost as often as it is looked for in mental disorder” for they result from “a primary alteration of consciouness” (p. 24). Bouchardss,” described shortening (Raccourcissement) of experienced duration in melancholia, prolongation (allongement) in mania and variations in either direction in emotional states. Cohen and Mezey” also found that Maudsley Hospital doctors under- or over-estimated time when subjected to a stressful situation (speaking in public); the authors speculated that the altered responses might have been mediated by depersonalization experiences. Depersonalization (defined as self-estrangement and body image diffusion) has indeed been found to be associated with feelings of temporal disintegration in 37 acutely psychotic patients.‘* Mezey and Cohen” reported that patients suffering from affective disorder over-produced time (e.g. measured a 30 sets. interval as being 40 sets.) and that this impairment continued after clinical improvement; however their ability to produce time remained unimpaired. Lehmann4’ also found that 14 depressive patients over-estimated time reproduction and under-estimated time production. It can be predicted therefore that severe affective disorder, of the
DISORIENTATION
STATES
483
type that leads to depressive “pseudodementia” may also give rise to impairment in time estimation or worse. Indeed patients with depressive stupor may on occasions be disorientated.74 Time Disorientation
in Schizophreniu
Regis described a subgroup of patients suffering from dementia praecox who exhibited confusion and disorientation.” Jung however stated that dementia praecox patients only give the impression of disorientation for they pay preferential attention to their “illusions”, but in fact remain correctly orientated.” Likewise Bleuler believed that there was no “primary” failure of temporal orientation in dementia praecox” and so did Kraepelin although he found that in the stuporous and severely agitated patient “perception of the environment may be occasionally disordered”.” It would seem therefore that these early authors did not consider verbal descriptions of distortions in time sense to be evidence for real time disorientation: later writers however did: for example Minkowski,4”,7” Schilde?jO and Seeman” have described the distortions in time experience complained of by schizophrenic patients as a fundamental aspect of the disease. Measurements of time production and reproduction have also been carried out in schizophrenic patients. Garza and Worchell” found that schizophrenics. who had been at least 2 years in hospital, were significantly poorer than controls on all time orientation tests. Ciompi” reported a female patient with “pseudoecstasy” who experienced telescoped perceptions of past, present and future; Rabins4 found schizophrenic patients to be significantly poorer than nonpsychotics in judging long time intervals and Guertin and Rabin” consider this to reflect a functional disability. Goldstone” found that pharmacotherapy reduced over- and underestimation of duration in schizophrenic patients. An age effect may enhance overestimation of time by schizophrenics.” Although these descriptive studies show some agreement, their validity is doubtful as the diagnostic criteria for schizophrenia used antedate the definitional readjustments carried out in the 1970’s. It is also unclear whether testing was done during the acute or chronic stages of the disease or whether patients had already received electroconvulsive therapy or insulin coma treatment. However some evidence has recently been marshalled concerning the presence of disorientation during the defect state. For example Le Guen” has described the “congealed time” syndrome (syndrome du temps fige) in patients who deny that any time has elapsed since the beginning of their illness. A similar disturbance has been described by Crow and Mitchell*’ in chronic male schizophrenic patients who believed themselves to be five or more years younger than they really were; however, this finding is marred by the fact that no information is provided on the cognitive state of the sample. Likewise Sztulman” has reported in schizophrenic patients a dissociation (“schizochronic”) between perception of “sensory-motor” time and disrupted “lived time” (temps vecu) and Letemendia and Harri? found that chlorpromazine worsened disorientation in a group of untreated chronic schizophrenics. Some evidence is available that during the acute stage cognitive state is
4&l
G. E. BERRIOS
relevant to temporal orientation in psychotic patients. For example it has been found that distortions of time sense are greater in patients with paranoid delusions than in any other acute psychiatric groupa and that there is a correlation between temporal disorganization, depersonalization and persecutory idealization;90,9’ this however is not specific to schizophrenia and may also be present in toxic states induced by tetrahydrocannabitol and alcohol.9z Joslyn and Hutzell@ on the other hand have found no significant difference on the Benton’s test49 between schizophrenic patients and normal controls; furthermore hospitalized schizophrenic patients were less likely to be disorientated to time than brain damaged patients. No clear evidence therefore exists that disorientation is a primary disorder in schizophrenia; some patients, however, may be disorientated either because they are confused or suffer from cognitive impairment (not necessarily related to their primary condition) or have been affected by neuroleptics or other organic treatments. FAILURE IN SPACE ORIENTATION Psychiatric spatial disorientation is diagnosed when the patient is unable (1) to reply correctly to space orientation questions or, (2) to orientate himself in his own surrounding or in the hospital (after a reasonable period of time since admission has elapsed). Verbal and behavioural space orientation can be found dissociated in clinical practice. Often disorientation is accompanied by confusion@’ of fluctuating course, and by a tendency to mistake the unfamiliar for the familiar.” Porot and Planche6’ consider “temporospatial disorientation” as a pathognomonic sign of mental confusion. The psychiatric usage may also include (1) the space orientation failure found in Korsakoff’s states which is believed to result from memory defect and be associated with confabulation40993 and mammillary body or hippocampal damage;94 and (2) the space disorientation described in relation to dementia1 states.6’995.” Spatial disorientation is diagnosed in neurospsychology when a subject is unable to apprehend “spatial relationships among or within objects”. In clinical terms this means that he may be unable to localize objects in space; trace a path or follow a route; memorize the location of objects or places; read, count or exercise adequate visuoconstructive ability.97 Some also include the disorders of the body schema.‘5,98 Neuropsychologists have therefore endeavoured to delineate symptom-complexes and search for their anatomical correlates. Early in the centuryW,‘OOv’O’ the terms disturbance of “spatial orientation” and of “the sense of space” were used to refer to specific disorientation states and believed to result from visual agnosia.“* Currently however two overlapping groups of disorders seem to be distinguished, according to whether disorientation results from cortica1”,‘5.97 or subcortical pathology (e.g. hippocampus and its connections).94 This notwithstanding psychiatric and neuropsychological usage are sometimes conflated. For example Kraupl-Taylor’03 states that “Disorientation in place shows itself mainly in a failure to perceive or remember spatial relations or to distinguish right from left” and considers it to be an amnestic symptom; other authors consider the fundamental problem to be a defect in attention.38,59
485
DISORIENTATION STATES
Spatial Disorientation
in the Organic Mental States
Space orientation requires that the subject be able to update the internal representation of his contour and also project the image of his own body in relation to his cognitive map. Two systems therefore seem to be required for correct orientation. One to allow the subject to gather and store information, the other to monitor and update the internal map. O’Keefe and Nadel refer to these as the “place” and “misplace” systems, respectively.94 The place system permits the subject to “locate himself in a familiar environment without reference to any specific sensory input, to go from one place to another independent of particular inputs (cues) or outputs (responses) and to link together conceptually parts of an environment which have never been experienced at the same time. The misplace system is primarily responsible for exploration, a species-specific behaviour which functions to build maps of new environments and to incorporate new information into existing maps.“y4 This analysis of spatial orientation has relevance to clincial practice. For example confused or delirious patients often believe that they are still at home and mistake the “unfamiliar for the familiar”;‘9~h”~“‘4occasionally they even believe that a close relative has been replaced by one impostor.‘“’ This behavioural rigidity of perseveration may reflect a dysfunction in the misplace system and a consequent inability to update the cognitive map. On the other hand demented patients may become spatially disorientated in response to a disruption of the place system,*” usually produced by a severe memory defect .40,‘06 Most clinicians agree that geographic disorientation (as seen in confusional states) is phenomenologically different from the discreet syndromes associated with parietal lobe dysfunction. The more so if the parietal function does not seem to be associated with topographical orientation (spatial map updating) or topographical memory.” Furthermore the fact that in clinical practice disorders of topographical orientation are correlated with disorders of memory”” suggests that the misplace system may be associated with the hippocampus:” the type of disorientation observed in Korsakoff’s syndrome illustrates well the association between memory and monitoring of space reference systems. FAILURES
IN PERSONAL
ORIENTATION
Person disorientation is usually interpreted as referring to the self i.e. as not knowing who one is.*‘.“’ Kraupl-Taylor’03 however seems to relate it to persons in the environment: “disorientation as to person is mainly due to dysmnesia so that the patients do not remember the individuality or social role of people they meet repeatedly”. Loss of personal orientation is a symptom’“~‘“~“” of which at least three varieties are described. Firstly, there is the fleeting sensation of perplexity experienced by subjects emerging from deep sleep, anaesthesia and toxic and twilight states; personal orientation in these cases is rapidly regained and the prognosis is good. Secondly, there is the group of acutely psychotic patients exhibiting delusional and hallucinatory states who believe themselves to be someone else; Kraepelm’ ” identified some of these states as “paraphrenia Thirdly, there is the group of patients suffering from organic phantastica”.
G. E. BERRIOS
486
mental disorders. Confused personal disorientation in the context of chronic brain disease carries a bad prognosis,“’ it is always accompanied by spatiotemporal disorientation and may develop insidiously with the episodes of disorientation becoming progressively longer until the patient’s identity becomes totally obliterated. On the other hand personal disorientation of sudden onset in the context of a moderate dementia1 state may signify an intercurrent cerebrovascular accident or other acute medical condition.“’ Longer lasting states must be differentiated from Transient Global Amnesia (T.G.A.)‘103”’ and fugue states.9X1’2T.G.A. affects the middle aged and elderly, is short lived (hours rather than days) and during an attack patients may have transient paresis and forget who they are which causes them distress and anxiety. Hysterical fugue states on the other hand occur in younger subjects, are accompanied by a loss of episodic memory, and last longer than T.G.A.9 DISCUSSION AND CONCLUSIONS Disorientation is a term used in clinical practice to refer to failures in orientation with respect to time, space, and person, whether temporary or long lasting and whether verbal or behavioural. It tends to be considered as an all-or-none phenomenon but the cut off points vary from clinician to clinician; clinico-pathological correlations are not available concerning its incidence, types, diagnostic, and prognostic value. Psychiatric disorientation is not uncommon amongst general hospital patients. It is a transient, fluctuating and under-diagnosed phenomenon often overshadowed by the clinical seriousness of the underlying physical condition. Clinicians consider it as an unwelcomed but secondary complication that is expected to resolve once the causal process has been dealt with. This practical view is probably acceptable in relation to delirious disorientation although there is some evidence that it may be correlated with fatal outcome.“’ Disorientation occurring in the context of dementia is long lasting, clinically obstructive and requires attention as it may constitute an important obstacle to management and rehabilitation. However little is known about the natural history of disorientation and its prognostic value in relation to the various dementia1 states. In terms of the available evidence organic disorientation seems to be a different phenomenon from the disorientation reported in relation to the functional psychoses. Nonetheless a great deal of overlap may occur and on occasions the disorientation exhibited by elderly demented patients can be interpreted as depending, at least partially, upon the severe delusional or hallucinatory overlay that often accompanies their condition.“3 Tests of production and reproduction of time on the other hand seem to be unrelated to the phenomenon called in this paper psychiatric disorientation; an equal lack of correlation seems to exist with the neuropsychological disorientation syndromes. This paper proposes a regional model (see Figure I) to integrate the psychiatric disorientations. Orientation can be tested by asking the patient a number of standard questions or by observing his behaviour. These two methods test what has been called verbal and behavioural orientation respectively. Although related these two forms of behaviour may on occasions break down
DISORIENTATION
STATES
487
r
I
I
Conscious
I Non-consci.ous
(speech)
(Eehaviour)
I
PUBLIC Ri'i.'FElj.ENCE SYSTEM
Partial Substitution J
Totzl 1 Substitution
Loss without Substitution \
1
II-----If-
1
Double
False Disorientation
Orientation
/
I Orientation
’ I
Functional
I
Organic ,
Psychoses Fig. 1:
Failures of Orientation
separately. Both verbal and behavioural orientation are defined in terms of their concordance with a public reference system. The model postulates that to certain pathological states (e.g. schizophrenia) the subject may develop a private reference system. The relative orientation of the subject in relation to public and private references systems may give rise to three types of orientation failure. Double orientation occurs when the subject orientates himself simultaneously or alternatively in relation to both systems; false orientation obtains when the subject shifts entirely from public to private reference system. True disorientation only obtains when no reference system is available to the subject. It is postulated by the model that double and false orientation are associated with the functional psychoses and true disorientation with the organic states. At this stage it would be speculative to touch upon possible mechanisms
488
G. E. BERRIOS
involved. It can be surmised, however, that true disorientation is likely to be associated with memory dysfunction of whatever origin while double and false orientation can only occur in fact if a degree of cognitive competence is preserved; on the other hand these orientation failures are related to delusional pathology and hence result from whatever impairment of informationprocessing function accompainies the delusional states. REFERENCES 1. Berrios GE: Delirium and Confusion in the 19th Century: A Conceptual History. Brit Joum Psych, 139:439-449, 1981 2. Meduna LJ: Oneirophrenia, the confusional state. Urbana, University of Illinois Press, 1950 3. Bond TC: Recognition of acute delirious mania. Arch Gen Psy, 37:553-554, 1980 4. Illing E: Des Stats delirants et confusionnels oniriques dans la psychose maniacodepressive. Annales Medico-psychologiques, 93, 592, 1934 5. Melges FT: Post-partum psychiatric syndromes. Psychosomatic Medicine, 30:95-108, 1968 6. Protheroe C: Puerperal Psychoses: A long term study 1927-1961. Brit Journ Psych, 115:9-30, 1969 7. Brockington IF, Schofield EM, Donnelly P et al: A clinical study of post-partum psychosis in Sandler, M. (Ed.) Mental Illness in pregnancy and the puerperium. Oxford, Oxford University Press, 1978, pp. 59-68 8. Stengel E: On aetiology of fugue states. Journ Ment Sci, 87:572-599, 1941 9. Akhtar S, Brenner I: Differential diagnosis of fugue-like states. Journ Clin Psych, 26:381-385, 1979 10. Critchley M: The parietal lobes. London, Edward Arnold and Co, 1953 11. Benton AL: Disorders of Spatial Orientation. In Vinken, PJ and Bruyn GW (Eds.) Handbook of Clinical Neurology, Vol. 3, Disorders of High Nervous Function, North Holland, Amsterdam, 1969, pp. 212-228 12. Kase CS, Troncoso JF, Court JE et al: Global Spatial disorientation. Journ Neuro Sci, 34~267-278, 1977 13. Paterson A, Zangwill OL: Recovery of spatial orientation in the post traumatic confusion state. Brain, 67:54-65, 1944 14. Paterson A, Zangwill OL: A case of topographical disorientation associated with a unilateral cerebral lesion. Brain, 68: 188-212, 1945 15. Hecaen H, Albert ML: Human Neuropsychology, New York, Wiley, 1978, pp. 224-237
16. Hamilton M: Fish’s clinical psychopathology. Revised Reprint, Bristol, Wright, p. 83, 1974 17. Ey H: Confusion et dtlire confusoonirique, Etude 24 in Etudes Psychiatriques. Paris, Desclee de Brouwer, pp. 326-368, 1954 18. Marchais P: Les processus psychopathologiques de l’adulte, Paris, Privat, 1981 19. Levin M: Varieties of Disorientation. Journ Men Sci, 102:619-623, 1956 20. Bash KW: Lehrbuch der Allgemainen Psychopathologic. Grundbegriffe und Klinik, Stuttgart, George Thieme, pp. 185-198, 1955 21. Ryle G: The concept of mind. London, Hutchinson, 1948 22. Metzger W: Psychologie (2nd Edition). Darmstadt, Steinkopff, pp. 140-142, 1954 23. Klein E: A Comprehensive Etymological Dictionary of the English Language. Vol. 2. Amsterdam, Elsevier, 1967 24. O.E.D. Oxford English Dictionary. Oxford, Oxford University Press, 1970 25. Mott FW: Arterial degenerations and diseases in Allbutt TC (Ed.) A system of medicine by many writers, Vol. IV, London, McMillan, 1899, pp. 294-344 26. Dupytren Baron de: On nervous delirium, Lancet, 1834, i, 919-923 27. Sutton T: Tracts on Delirium Tremens. . and on the Gout, London, on Peritonitis Thomas Underwood, 1813 28. Berrios GE: Stupor, a conceptual history. Psychological Medicine, 11:677-688, 1981 29. Falret J: Amnesie in Dechambre, A. (Ed.) Dictionnaire Encyclopedique des sciences mtdicales Vol. 3, Paris, Asselin and Masson, 1865, pp. 725-742 30. Winslow F: On obscure diseases of the brain and disorders of the mind, London. John W. Davies, 1861, p. 343 31. Bercherie P: Les Fondements de la clinique, Paris, La Bibliothtque d’Omicar?, 1980 32. Jastrow J: Orientation (Mental) in Baldwin, J.M. (Ed.) Dictionary of Philosophy and Psychology, Vol. 2, New York, McMillan. 1901 33. Wernicke C: Grundriss der Psychiatric, Leipzig, Thieme, 1906
DISORIENTATION
STATES
34. Janet P: Les obsessions et la psychasthenie, Vol. 1, Paris, Alcan, 1919 3.5. Konig, H: Zur Psychopathologic der Paralysis agitans. Archives fur Psychiatric und Nervenkrankheiten, 50:285-305, 1912 36. Jaspers K: General Psychopathology (Translated by Hamilton, M.) Manchester, Manchester University Press 37. Bleuler E: Textbook of Psychiatry. New York, McMillan, 1924 38. Cabaleiro Goas M: Temas Psiquiatricos, Madrid, Paz Montalvo, 1966 39. Strub RL. Black FW: Organic brain syndromes, Philadelphia, FA Davis, 1981 40. Zangwill OL: The amnesic syndrome in Whitty C.W.M. and Zangwill, O.L. (Eds.) Amnesia, 2nd Edition, London, Butterworths. 1977 pp. 104-l 17 41. Hesnard A: Les psychoses et les front&es de la folie, Paris, Flammarion, 1924 42. Gale RM (Ed.): The philosophy of time. A collection of Essays. London, McMillan, 1968 43. Lucas JR: A treatise on time and space. London, Methuen. 1973 44. Goody W: Disorders of orientation in space-time. Brit Journ Psych. 112:661-670, 1966 45. Minkowski E: La schizophrenic. Psydes schizoides et chopathologie des schizophrenes. Paris. Des&e de Brouwer, 1927 46. Lewis A: The experience of time in mental disorder. Proceedings of Royal Society of Medicine, 2.5:15-24, 1932 47. Lehmann HE: Time and psychopathology. Annals New York, Academy of Sciences. 138:798-821. 1967 48. Cohen J: Psychological time. Scientific American. 1964. November. 49. Benton AL. Allen MW van, Fogel ML: Temporal orientation in cerebral disease. Journ Nerv Ment Dis, 139:110-119. 1964 50. Cohen S. Mezey AG: The effect of anxiety on time judgement and time experience in normal persons. Journ Neurology. Neurosurgery Psychiatry, 24:266-268, 1961 5 I. Mezey AG. Cohen SI: The effect of depressive illness on time judgement and time experience. Journ Neourology, Neurosurgery Psychiatry, 24:269-270. 1961 52. Le Guen C: Troubles des conduites temporelles. Encyclopedic Mtdico-Chirurgicale. Psychiatric. Vol. 1 37136 A 10. Paris. Editions Techinques. 1963 53. Sztulman H: Psychometric du temps dans la schizophrenic. Annales Medico-Psychologiques. i:27-38. 1968
489 54. Strub RL. Black FW: The mental status examination in neurology. Philadelphia. FA Davies, 1977 55. Bouchard. R: Sur I’evaluation du temps dans certains troubles mentaux. These de Paris. Vigot f&es Editeurs, 1926 56. McFie J: Psychological testing in clinical neurology. Journ Nerv Ment Dis, 131:383-393. 1960 57. Lipowski ZJ: Delirium, acute brain failure in Man. Illinois, Thomas, 1980 58. Bleuler M: Acute concomitants of Physical Disease. In Benson DF, Blumer D (Eds.): Psychiatric Aspects of Neurological Disease. New York. Grune and Stratton, 1975. pp. 37-61 59. Chedru F, Geschwind N: Disorders of higher cortical functions in acute confusional states. Cortex. 8:395-41 I. 1972 60. Porot M, Planche R: Confusion Mentale. Encyclopedic Medico-Chirurgicale. 37240. A IO, 5 (Psychiatric), Paris, Editions Techniques. 1969 61. Allison RS: The senile brain. a clinical study. London. Edward Arnold. 1962 62. Goody W: Disorders of time sense in Vinken PJ, Bruyn GW (Eds.) Handbook of Clinical Neurology, Vol. 3. Disorders of Higher Nervous Activity, Amsterdam, North Holland. 1969 63. Levin HS, Benton AL: Temporal orientation in patients with brain disease. Applied Neurophysiology. 3856-60, 1975 64. Joslyn D. Hutzell RR: Temporal disorientation in schizophrenic and brain-damaged patients, Amer Journ Psych 136: 1220-1222. 1979 65. Coheen JJ: Disturbances in time discrimination in organic brain disease. Journ Nerv Ment Dis. 112:121-129. 1950 66. Ellen P. Powell E: Timing behaviour after lesions of zona incerta and mammillary body. Science, 141:828-830, 1963 67. Efron R: Temporal perception. aphasia and dej& vu. Brain. 86:403-424. 1963 68. Spiegel EA. Wycis HT. Orchinik C et al: Thalamic chronotaraxis. Amer Journ Psych. 113:97-10.5, 1956 69. Davidson GM: A syndrome of time agnosia. Journ Nerv Ment Dis. 94:336-343. 1941 70. Bouman L. Grtinbaum AA: Eine Storung de Chronognosie und ihre Bedeuting im bettreffenden Symptomenbild. Monatschrift fitt Psychiatric und Neurologie. 73: l-39. 1929 71. Beaudouin H. Bouchard K: Tests d’dvaluation du temps Annales Medico-Psychologiques, i:293-295. 1927
490
72. Freeman AM, Melges FT: Depersonalization and temporal disintegration in acute mental illness. Amer Joum Psych, 134:679-681, 1977 73. McAllister TW: Cognitive functioning in the affective disorders. Comp Psych, 22572-586, 1981 74. Berrios GE: Stupor Revisited. Comp Psych, 22:466-478, 1981 7.5. RCgis E: Precis de Psychiatric, Paris: Octave Doin, 1906 76. Jung CG: The Psychology of Dementia Praecox in The Collected Works, Vol. 3, London, Routledge and Kegan Paul. 77. Bleuler E: Dementia Praecox or the group of the schizophrenias. International Universities Press, New York, 1950 78. Kraepelin E: Dementia Praecox and Paraphrenia. Edinburgh, Livingstone 1919 79. Minkowski E: Bergson’s conceptions as applied to psychopathology. Journ Nerv Ment Dis, 63:553-561, 1926 80. Schilder P: Psychopathology of time. Journ Nerv Ment Dis, 83:530-546, 1936 81. Seeman MV: Time and schizophrenia. Psychiatry, 39:189-195, 1976 82. Garza CO de la, Worchel P: Time and space disorientation in schizophrenics. Journ Abnormal Psychology, 52:191-194, 1956 83. Ciompi L: Uber abnormes Zeiterleben bei einer Schizophrenen. Psychiatria et Neurologia, 142: 100-121, 1961 84. Rabin AT: Time estimation of schizophrenics and non-psychotics. Journ Clin Psychology, 13:88-90, 1957 85. Guertin WH, Rabin AI: Misperception of time in schizophrenia. Psychological Reports, 7:57-58, 1960 86. Goldstone S: The human clock: a framework for the study of healthy and deviant time perception. Annals New York Academy of Science, 138:767-783, 1967 87. Crow TJ, Mitchell WS: Subjective age in chronic schizophrenia: evidence for a subgroup of patients with defective learning capacity? Brit Joum Psych, 126:360-363, 1975 88. Letemendia FJJ, Harris AD: Chlorpromazine and the untreated chronic schizophrenic: a long term therapeutic trial. Brit Journ Psych, 113:950-958, 1967 89. Melges FT, Fougerousse CE: Time, sense, emotions and acute mental illness. Journ Psych Res, 4:127-140, 1966 90. Freeman AM, Melges FT: Temporal disorganization, depersonalization and persecutory ideation in acute mental illness. Amer Journ Psych, 135:123-124, 1978
G. E. BERRIOS
91. Melges FT, Freeman AM: Temporal disorganization and inner-outer confusion in acute mental illness. Amer Joum Psych, 134:874-877, 1977 92. Melges FT, Tinklenberg JR, Deardorff CM et al: Temporal disorganization and delusional-like ideation. Processes induced by Hashish and Alcohol. Arch Gen Psych, 30:855-861, 1974 93. Mercer B, Wapner W, Gardner H et al: A study of confabulation. Arch Neurology, 34~429-433, 1977 94. O’Keefe J, Nadel L: The hippocampus as a cognitive map. Oxford, Clarendon Press, 1978 95. Williams M: Spatial disorientation in senile dementia. Journ Ment Sci, 102:291-299, 1956 96. Ajuriaguerra J de, Richard J, Rodriguez R et al: Quelques aspects de la d&integration des praxies ideomotrices dans les demences de grand age. Cortex, 2:434-462, 1966 97. Semmes J, Weinstein S, Ghent L, et al: Correlates of impaired orientation in personal and extrapersonal space. Brain, 86:747-772, 1963 98. Lezak MD: Neuropsychological assessment. New York, Oxford University Press, 1977 99. Badal J: Contribution a l’etude des &cites psychiques: alexie, agraphie, hemianopsie inferieure, troubles du sens de I’espace. Archives Ophtalmologiques, 8:97-l 17, 1888 100. Meyer 0: Ein und doppelseitige homonyme Hemianopsie mit Orientierungsst6rungen. Monatschrift fur Psychiatric und Neurologie, 8:440-456, 1900 101. Balint R: Seelenlahmung des “schauens”. optische ataxie, raumliche Storung der Aufmersamkeit. Monatschrift fur Psychiatrie und Neurologie, 25:51-81, 1909 102. Holmes G: Disturbances of visual orientation. Brit Joum Ophth, 2449-469; 506-516, 1918 103. Taylor F, Krlupl: Psychopathology, its causes and symptoms. London, Butterworths, 1966 104. Levin M: Spatial disorientation in delirium. Amer Journ Psych, 113:174-175, 1956a 105. McCallum WAG: Capgras syndrome with an organic basis. Brit Journ Psych, 123:639-642, 1973 106. Benson FD, Gardner H, Meadows JC: Reduplicative paramnesia. Neurology, 26:147-151, 1976 107. Scharfetter C: Allgemeine Psychopathologie, Stuttgart, Georg. Thieme, 1976
DISORIENTATION
STATES
108. Rabins PV, Folstein MF: Delirium and dementia: Diagnostic criteria and fatality rates. Brit Journ Psych, 140:49-153, 1982 109. Lishmann WA: Organic Psychiatry. Oxford, Blackwells, 1978 110. Heathfield KWG, Croft PB, Swash M: The syndrome of transient global amnesia. Brain. 96729-735, 1973
491
111. Fisher CM, Adams RD: Transient Global Amnesia. Acta Neurologica Scandinavica, Supplement 9, pp. 7-83, 1964 112. Janet P: Etat mental des HystCriques. Rueff, Paris, pp. 79-121 113. Ballinger BR, Reid AH, Heather. BB: Cluster Analysis of symptoms in elderly demented patients. Brit Journ Psych, 140:257-X2. 1982
E. Berrios
T
EMPOROSPATIAL Disorientation has been regarded since the late 19th century as the tangible expression of clouding of consciousness and hence as a clinical indication of organic mental disorder.’ At the same time disorientation-like states have been described accompanying some forms of acute schizophrenia,’ of mania,3 of depression4 of puerperal psychoses,‘.‘.’ and of fugue states. 8.9 In addition, the same term is also used to refer to specific orientation failures associated with cerebra-cortical syndromes.“‘~“~“~‘3~‘4~‘l.‘i Because it is not clear whether the various mental states mentioned are connected two views have developed. The unitary hypothesis states that all orientation failures result from perturbation of a common mechanism;‘h.‘7 the multimodal view on the other hand considers psychiatric and neurological disorientation as separate states. A variant of this view suggests that even temporal and spatial forms of disorientation may be potentially disociable.‘x.‘y.“’ Disagreement has arisen from many sources. Orientation failures are elusive clincial states; it is unclear whether clinical presentation and aetiology are related, for example whether delirious disorientation is related, say, to parietal lobe dysfunction; it is equally obscure whether orientation for time, space, and person depend upon different psychological and neural systems and whether this is the explanation for the clinical fact that orientation in some dimensions may be more resistant to breakdown than orientation in others.‘” Since standard techniques to elicit the phenomenon are not yet available research results are hardly comparable. As a consequence there is uncertainty as to the clinical value of this symptom. Disorientation may, after all, turn out to be only a crude index of cognitive failure. This paper organizes the field from the historical, clinical and conceptual viewpoints and suggests a model for the analysis of global disorientation in relation to delirium and the functional psychoses. It does not include however the so-called analysis of “chrono and space agnosias” as it takes the view that they constitute separate clinical phenomena. TERMS AND CONCEPTS Disorientation is used both as a descriptive and as an explanatory concept. Like the terms hallucination or delusion, it refers to an ongoing mental state: but unlike them it identifies a failure in “knowing that” (verbal orientation) and “knowing what” (behavioural orientation).” Orientation entails a fine
Depurtment of Psychiatry, Uni\lersity of Cambridge. E. Berrios, MA; D.Phil. Sci. (Oxon): MD: FRCPsych..
From G.
Department Address
of Psychiutry. reprint
Lecturer
and
Hospital
(Level
0
requests 4). Hills
of Cambridge.
to G. E. Berrios,
Consultant,
1982 by Grune
Comprehensive
University Department Road,
& Stratton.
Psychiatry,
MA:
Cambridge. Inc.
Vol.
23,
Cambridge.
D.Phil.
of Psychiatp.
Cambridge, Uni\,rrsity
and Con.crc~ta~~t.
England
Sci. (Oxon): Uniwrsity
England
Lecturer MD:
FRCPsych..
of‘ Cumhridge.
lJni\,er.\it>
Addenbrooke’c
England
OOlO-44041821230510010$1.00I0
No.
5
(SeptJOct.1,
1982
479
G. E. BERRIOS
480
tuning between the subject and the internal representation he forms of the corresponding public reference system.” Since the latter changes the subject must be able to update his internal map. Breakdowns in orientation may therefore result from an inability to: (1) perceive the relevant reference system; (2) utilize the information thus obtained in the updating of the internal map; (3) recall the updated map; (4) carry out a match-mismatch operation; (5) act upon detected mismatching. Occasionally failures in orientation may also result from interference or confusion caused by the presence of a new reference system (e.g. delusional) which is privately generated by the subject. In this paper “Orientation failure” will be used as a general term to refer to any clinical situation in which a dislocation can be observed between the orientation behaviour of the subject (whether verbal or nonverbal) and the consensual reference system. “False orientation” will name a situation when the failure results from reorientation in relation to a pathological private reference system. “Double orientation” will describe the clinical situation in which the subject may be orientated, simultaneously or alternatively, in relation to a private and public reference system. “Disorientation” (proper) will refer to an orientation failure in which the subject has lost all ability to orientate himself; this may result from cognitive impairment or unavailability of reference systems or both. HISTORICAL
ASPECTS
The English word “orientation” derives from the French “orienter”23 and was first used as a scientific term in astronomy.24 Mott referred as “imperfect orientation” one of the psychological disturbances caused by cerebral arteriosclerosis. Disorientation, as a symptom, did not escape observation in earlier times and was occasionally described in association with acute brain syndromes,26v27 stupor,28 transient memory disturbance29s30 and reduction in mental function.3’ By the end of the century and under the influence of the localizationist drive mental orientation began to be considered as an independent function.32 For example its failures were subdivided by Wernicke into autopsychic (personal identity); somatopsychic (corporality), and allopsychic (time and place).33 Janet used the term “feeling of disorientation” to describe the experience of loss of appreciation of the spatial relationship that objects hold with one another,34 and Konig to characterize the confusion observed in some cases of Parkinson’s disease.3s Jaspers identified four types of disorientation: amnesic, delusional, apathetic and clouded.36 Bleuler drew attention to the phenomenon of psychotic “double orientation”.37 These early views have influenced current clinical practice; for example the orientation failure observed in delirium is considered as resulting from a temporary disturbance of consciousness;7,38.39 that of Korsakoff’s states as stemming from a failure of memory4’ and that of the functional psychoses as secondary to delusional beliefs.37s4’ FAILURES
IN TIME ORIENTATION
The complex issues involved in the definition and perception of time have encouraged speculation both at a genera142,43and at a clinical leve1.44,45Time
481
DISORIENTATION STATES
disorientation has been described in association with most psychiatric conditions;4” this is right if a wide definition of the symptom is utilized; for example patients experiencing distortions in their feelings of duration may be regarded as disorientated in a loose sense. On the other hand, the use of a narrow definition, for example one based upon objective testing of the patient’s perception of time, yields a lower incidence of orientation failures. The diagnostic value of these definitions has not yet been properly assessed. Time orientation depends upon the monitoring of three time reckoning systems. The offical time (OT) reference system,47 as kept by public time-markers. which the individual perceives as a continuous flow but conceptualizes as a nest of subunits (year, month and date); secondly “cued time” (CT) (e.g. awareness of time of day or of season of year) whose adequate monitoring relies on the correct recognition of cues;” these can be external (e.g. climate, social rituals) or internal (proprioceptive sensations). The third time reckoning mechanism refers to the individual’s subjective experience of duration (i.e. “personal time”).48 Since probably different cognitive functions are involved in the monitoring of these three systems independent breakdown of each may occur in response to different noxae. Thus, clinical observation shows that official and cued time disorientation are often associated with organic disorder,49 while distortions in the perception of personal time are common in relation to functional disorders such as severe anxiety.5” obsessional states,46 depression’ and schizophrenia.4h.S’.” Temporal orientation is believed to be more vulnerable than space or personal orientation.lh.‘x.‘” Verbal orientation is tested by asking standard questions which assess synchronization to different reckoning systems;‘4 incorrect answers beyond certain limits are considered as pathological but cut off points vary from clinician to clinician. Thus Benton et a1.49 have shown that clinical judgement alone results in an unacceptable number of false negatives. At the beginning of the century Bouchard”; used the testing strategy of asking the subject to “produce”, (by tapping or pacemaking) or to “reproduce” time, i.e. to judge the duration of a given unit of official time. The relevance of this measurement to time disorientation has been called into question.“‘.” Temporal Disorientation
in the Orgunic Mental States
States of altered cognition are often associated with temporal disorientation. Delirium’7~“8and confusional statess9.60 are as a rule accompanied by fluctuating temporal disorientation and so are the dementia1 states;6’.h’ likewise between 25 and 39 per cent of brain damaged subjects exhibit a form of time disorientation63,h4 and so do patients with diffuse cortical disease.6s In these cases the parsimonious explanation is that time disorientation may result from memory, attention or perceptual failure. On occasions, however, time disorientation has been described as an isolated symptom and this raises the issue of whether it depends upon dysfunction of a particular neural network. For example Ellen and Powell’” found that the “scallop” response profile in rats, i.e. the distribution of responding during fixed interval reinforcement is affected by lesions in the zona incerta. Likewise
G. E. BERRIOS
482
in humans it has been suggested by Efron6’ that “there is a fundamental mechanism or process related to the requirement of “time-1abelling” of input or output signals which is located in the dominant temporal lobe” dysfunction of which, would explain the disturbance of subjective time sense seen in temporal lobe epilepsy. Spiegel et a1.68 have also described impairment of temporal orientation in schizophrenic patients (without disorientation in space) after lesions in the dorsomedial thalamic nucleus; patients were confused regarding date, season of the year, and time of day and mis-stated their age and that of their children. This defect, referred to as “chronotaraxis”, was however transitory and occurred independently from clouding of consciouness. Some of these patients however also exhibited memory defect which could explain their time disorientation. The same cautionary note must apply to the so-called Time Agnosia syndrome69 described in 7 male patients with traumatic, alcoholic or vascular brain disturbance who after emerging from unconsciousness showed amnesia, confusion, time disorientation and difficulty in estimating time intervals; in contrast their appreciation of rhythm was satisfactory. Bowman and Grtinbaum’” have described the symptom of “chronognosie” resulting from a viral infection; this patient however also exhibited cognitive dysfunction. Critchley” has stated that “Pure temporal disorientation, that is, occurring independently of spatial disorders, is a rare phenomenon” and listed a number of clinical situations in which a failure of “Zeitauffassung” (Time apperception) can be assumed. Amongst these he includes inability to judge the passage of time; difficulty in estimating the approximate hour of the day, gross disorientation in time and the feeling of time rushing past. Time Disorientation
in the Affective
Disorders
An early paper by Lewis included examples of disturbances in personal time experience in a number of psychiatric disorders.46 He concluded that a disorder of time-consciousness “may be found almost as often as it is looked for in mental disorder” for they result from “a primary alteration of consciouness” (p. 24). Bouchardss,” described shortening (Raccourcissement) of experienced duration in melancholia, prolongation (allongement) in mania and variations in either direction in emotional states. Cohen and Mezey” also found that Maudsley Hospital doctors under- or over-estimated time when subjected to a stressful situation (speaking in public); the authors speculated that the altered responses might have been mediated by depersonalization experiences. Depersonalization (defined as self-estrangement and body image diffusion) has indeed been found to be associated with feelings of temporal disintegration in 37 acutely psychotic patients.‘* Mezey and Cohen” reported that patients suffering from affective disorder over-produced time (e.g. measured a 30 sets. interval as being 40 sets.) and that this impairment continued after clinical improvement; however their ability to produce time remained unimpaired. Lehmann4’ also found that 14 depressive patients over-estimated time reproduction and under-estimated time production. It can be predicted therefore that severe affective disorder, of the
DISORIENTATION
STATES
483
type that leads to depressive “pseudodementia” may also give rise to impairment in time estimation or worse. Indeed patients with depressive stupor may on occasions be disorientated.74 Time Disorientation
in Schizophreniu
Regis described a subgroup of patients suffering from dementia praecox who exhibited confusion and disorientation.” Jung however stated that dementia praecox patients only give the impression of disorientation for they pay preferential attention to their “illusions”, but in fact remain correctly orientated.” Likewise Bleuler believed that there was no “primary” failure of temporal orientation in dementia praecox” and so did Kraepelin although he found that in the stuporous and severely agitated patient “perception of the environment may be occasionally disordered”.” It would seem therefore that these early authors did not consider verbal descriptions of distortions in time sense to be evidence for real time disorientation: later writers however did: for example Minkowski,4”,7” Schilde?jO and Seeman” have described the distortions in time experience complained of by schizophrenic patients as a fundamental aspect of the disease. Measurements of time production and reproduction have also been carried out in schizophrenic patients. Garza and Worchell” found that schizophrenics. who had been at least 2 years in hospital, were significantly poorer than controls on all time orientation tests. Ciompi” reported a female patient with “pseudoecstasy” who experienced telescoped perceptions of past, present and future; Rabins4 found schizophrenic patients to be significantly poorer than nonpsychotics in judging long time intervals and Guertin and Rabin” consider this to reflect a functional disability. Goldstone” found that pharmacotherapy reduced over- and underestimation of duration in schizophrenic patients. An age effect may enhance overestimation of time by schizophrenics.” Although these descriptive studies show some agreement, their validity is doubtful as the diagnostic criteria for schizophrenia used antedate the definitional readjustments carried out in the 1970’s. It is also unclear whether testing was done during the acute or chronic stages of the disease or whether patients had already received electroconvulsive therapy or insulin coma treatment. However some evidence has recently been marshalled concerning the presence of disorientation during the defect state. For example Le Guen” has described the “congealed time” syndrome (syndrome du temps fige) in patients who deny that any time has elapsed since the beginning of their illness. A similar disturbance has been described by Crow and Mitchell*’ in chronic male schizophrenic patients who believed themselves to be five or more years younger than they really were; however, this finding is marred by the fact that no information is provided on the cognitive state of the sample. Likewise Sztulman” has reported in schizophrenic patients a dissociation (“schizochronic”) between perception of “sensory-motor” time and disrupted “lived time” (temps vecu) and Letemendia and Harri? found that chlorpromazine worsened disorientation in a group of untreated chronic schizophrenics. Some evidence is available that during the acute stage cognitive state is
4&l
G. E. BERRIOS
relevant to temporal orientation in psychotic patients. For example it has been found that distortions of time sense are greater in patients with paranoid delusions than in any other acute psychiatric groupa and that there is a correlation between temporal disorganization, depersonalization and persecutory idealization;90,9’ this however is not specific to schizophrenia and may also be present in toxic states induced by tetrahydrocannabitol and alcohol.9z Joslyn and Hutzell@ on the other hand have found no significant difference on the Benton’s test49 between schizophrenic patients and normal controls; furthermore hospitalized schizophrenic patients were less likely to be disorientated to time than brain damaged patients. No clear evidence therefore exists that disorientation is a primary disorder in schizophrenia; some patients, however, may be disorientated either because they are confused or suffer from cognitive impairment (not necessarily related to their primary condition) or have been affected by neuroleptics or other organic treatments. FAILURE IN SPACE ORIENTATION Psychiatric spatial disorientation is diagnosed when the patient is unable (1) to reply correctly to space orientation questions or, (2) to orientate himself in his own surrounding or in the hospital (after a reasonable period of time since admission has elapsed). Verbal and behavioural space orientation can be found dissociated in clinical practice. Often disorientation is accompanied by confusion@’ of fluctuating course, and by a tendency to mistake the unfamiliar for the familiar.” Porot and Planche6’ consider “temporospatial disorientation” as a pathognomonic sign of mental confusion. The psychiatric usage may also include (1) the space orientation failure found in Korsakoff’s states which is believed to result from memory defect and be associated with confabulation40993 and mammillary body or hippocampal damage;94 and (2) the space disorientation described in relation to dementia1 states.6’995.” Spatial disorientation is diagnosed in neurospsychology when a subject is unable to apprehend “spatial relationships among or within objects”. In clinical terms this means that he may be unable to localize objects in space; trace a path or follow a route; memorize the location of objects or places; read, count or exercise adequate visuoconstructive ability.97 Some also include the disorders of the body schema.‘5,98 Neuropsychologists have therefore endeavoured to delineate symptom-complexes and search for their anatomical correlates. Early in the centuryW,‘OOv’O’ the terms disturbance of “spatial orientation” and of “the sense of space” were used to refer to specific disorientation states and believed to result from visual agnosia.“* Currently however two overlapping groups of disorders seem to be distinguished, according to whether disorientation results from cortica1”,‘5.97 or subcortical pathology (e.g. hippocampus and its connections).94 This notwithstanding psychiatric and neuropsychological usage are sometimes conflated. For example Kraupl-Taylor’03 states that “Disorientation in place shows itself mainly in a failure to perceive or remember spatial relations or to distinguish right from left” and considers it to be an amnestic symptom; other authors consider the fundamental problem to be a defect in attention.38,59
485
DISORIENTATION STATES
Spatial Disorientation
in the Organic Mental States
Space orientation requires that the subject be able to update the internal representation of his contour and also project the image of his own body in relation to his cognitive map. Two systems therefore seem to be required for correct orientation. One to allow the subject to gather and store information, the other to monitor and update the internal map. O’Keefe and Nadel refer to these as the “place” and “misplace” systems, respectively.94 The place system permits the subject to “locate himself in a familiar environment without reference to any specific sensory input, to go from one place to another independent of particular inputs (cues) or outputs (responses) and to link together conceptually parts of an environment which have never been experienced at the same time. The misplace system is primarily responsible for exploration, a species-specific behaviour which functions to build maps of new environments and to incorporate new information into existing maps.“y4 This analysis of spatial orientation has relevance to clincial practice. For example confused or delirious patients often believe that they are still at home and mistake the “unfamiliar for the familiar”;‘9~h”~“‘4occasionally they even believe that a close relative has been replaced by one impostor.‘“’ This behavioural rigidity of perseveration may reflect a dysfunction in the misplace system and a consequent inability to update the cognitive map. On the other hand demented patients may become spatially disorientated in response to a disruption of the place system,*” usually produced by a severe memory defect .40,‘06 Most clinicians agree that geographic disorientation (as seen in confusional states) is phenomenologically different from the discreet syndromes associated with parietal lobe dysfunction. The more so if the parietal function does not seem to be associated with topographical orientation (spatial map updating) or topographical memory.” Furthermore the fact that in clinical practice disorders of topographical orientation are correlated with disorders of memory”” suggests that the misplace system may be associated with the hippocampus:” the type of disorientation observed in Korsakoff’s syndrome illustrates well the association between memory and monitoring of space reference systems. FAILURES
IN PERSONAL
ORIENTATION
Person disorientation is usually interpreted as referring to the self i.e. as not knowing who one is.*‘.“’ Kraupl-Taylor’03 however seems to relate it to persons in the environment: “disorientation as to person is mainly due to dysmnesia so that the patients do not remember the individuality or social role of people they meet repeatedly”. Loss of personal orientation is a symptom’“~‘“~“” of which at least three varieties are described. Firstly, there is the fleeting sensation of perplexity experienced by subjects emerging from deep sleep, anaesthesia and toxic and twilight states; personal orientation in these cases is rapidly regained and the prognosis is good. Secondly, there is the group of acutely psychotic patients exhibiting delusional and hallucinatory states who believe themselves to be someone else; Kraepelm’ ” identified some of these states as “paraphrenia Thirdly, there is the group of patients suffering from organic phantastica”.
G. E. BERRIOS
486
mental disorders. Confused personal disorientation in the context of chronic brain disease carries a bad prognosis,“’ it is always accompanied by spatiotemporal disorientation and may develop insidiously with the episodes of disorientation becoming progressively longer until the patient’s identity becomes totally obliterated. On the other hand personal disorientation of sudden onset in the context of a moderate dementia1 state may signify an intercurrent cerebrovascular accident or other acute medical condition.“’ Longer lasting states must be differentiated from Transient Global Amnesia (T.G.A.)‘103”’ and fugue states.9X1’2T.G.A. affects the middle aged and elderly, is short lived (hours rather than days) and during an attack patients may have transient paresis and forget who they are which causes them distress and anxiety. Hysterical fugue states on the other hand occur in younger subjects, are accompanied by a loss of episodic memory, and last longer than T.G.A.9 DISCUSSION AND CONCLUSIONS Disorientation is a term used in clinical practice to refer to failures in orientation with respect to time, space, and person, whether temporary or long lasting and whether verbal or behavioural. It tends to be considered as an all-or-none phenomenon but the cut off points vary from clinician to clinician; clinico-pathological correlations are not available concerning its incidence, types, diagnostic, and prognostic value. Psychiatric disorientation is not uncommon amongst general hospital patients. It is a transient, fluctuating and under-diagnosed phenomenon often overshadowed by the clinical seriousness of the underlying physical condition. Clinicians consider it as an unwelcomed but secondary complication that is expected to resolve once the causal process has been dealt with. This practical view is probably acceptable in relation to delirious disorientation although there is some evidence that it may be correlated with fatal outcome.“’ Disorientation occurring in the context of dementia is long lasting, clinically obstructive and requires attention as it may constitute an important obstacle to management and rehabilitation. However little is known about the natural history of disorientation and its prognostic value in relation to the various dementia1 states. In terms of the available evidence organic disorientation seems to be a different phenomenon from the disorientation reported in relation to the functional psychoses. Nonetheless a great deal of overlap may occur and on occasions the disorientation exhibited by elderly demented patients can be interpreted as depending, at least partially, upon the severe delusional or hallucinatory overlay that often accompanies their condition.“3 Tests of production and reproduction of time on the other hand seem to be unrelated to the phenomenon called in this paper psychiatric disorientation; an equal lack of correlation seems to exist with the neuropsychological disorientation syndromes. This paper proposes a regional model (see Figure I) to integrate the psychiatric disorientations. Orientation can be tested by asking the patient a number of standard questions or by observing his behaviour. These two methods test what has been called verbal and behavioural orientation respectively. Although related these two forms of behaviour may on occasions break down
DISORIENTATION
STATES
487
r
I
I
Conscious
I Non-consci.ous
(speech)
(Eehaviour)
I
PUBLIC Ri'i.'FElj.ENCE SYSTEM
Partial Substitution J
Totzl 1 Substitution
Loss without Substitution \
1
II-----If-
1
Double
False Disorientation
Orientation
/
I Orientation
’ I
Functional
I
Organic ,
Psychoses Fig. 1:
Failures of Orientation
separately. Both verbal and behavioural orientation are defined in terms of their concordance with a public reference system. The model postulates that to certain pathological states (e.g. schizophrenia) the subject may develop a private reference system. The relative orientation of the subject in relation to public and private references systems may give rise to three types of orientation failure. Double orientation occurs when the subject orientates himself simultaneously or alternatively in relation to both systems; false orientation obtains when the subject shifts entirely from public to private reference system. True disorientation only obtains when no reference system is available to the subject. It is postulated by the model that double and false orientation are associated with the functional psychoses and true disorientation with the organic states. At this stage it would be speculative to touch upon possible mechanisms
488
G. E. BERRIOS
involved. It can be surmised, however, that true disorientation is likely to be associated with memory dysfunction of whatever origin while double and false orientation can only occur in fact if a degree of cognitive competence is preserved; on the other hand these orientation failures are related to delusional pathology and hence result from whatever impairment of informationprocessing function accompainies the delusional states. REFERENCES 1. Berrios GE: Delirium and Confusion in the 19th Century: A Conceptual History. Brit Joum Psych, 139:439-449, 1981 2. Meduna LJ: Oneirophrenia, the confusional state. Urbana, University of Illinois Press, 1950 3. Bond TC: Recognition of acute delirious mania. Arch Gen Psy, 37:553-554, 1980 4. Illing E: Des Stats delirants et confusionnels oniriques dans la psychose maniacodepressive. Annales Medico-psychologiques, 93, 592, 1934 5. Melges FT: Post-partum psychiatric syndromes. Psychosomatic Medicine, 30:95-108, 1968 6. Protheroe C: Puerperal Psychoses: A long term study 1927-1961. Brit Journ Psych, 115:9-30, 1969 7. Brockington IF, Schofield EM, Donnelly P et al: A clinical study of post-partum psychosis in Sandler, M. (Ed.) Mental Illness in pregnancy and the puerperium. Oxford, Oxford University Press, 1978, pp. 59-68 8. Stengel E: On aetiology of fugue states. Journ Ment Sci, 87:572-599, 1941 9. Akhtar S, Brenner I: Differential diagnosis of fugue-like states. Journ Clin Psych, 26:381-385, 1979 10. Critchley M: The parietal lobes. London, Edward Arnold and Co, 1953 11. Benton AL: Disorders of Spatial Orientation. In Vinken, PJ and Bruyn GW (Eds.) Handbook of Clinical Neurology, Vol. 3, Disorders of High Nervous Function, North Holland, Amsterdam, 1969, pp. 212-228 12. Kase CS, Troncoso JF, Court JE et al: Global Spatial disorientation. Journ Neuro Sci, 34~267-278, 1977 13. Paterson A, Zangwill OL: Recovery of spatial orientation in the post traumatic confusion state. Brain, 67:54-65, 1944 14. Paterson A, Zangwill OL: A case of topographical disorientation associated with a unilateral cerebral lesion. Brain, 68: 188-212, 1945 15. Hecaen H, Albert ML: Human Neuropsychology, New York, Wiley, 1978, pp. 224-237
16. Hamilton M: Fish’s clinical psychopathology. Revised Reprint, Bristol, Wright, p. 83, 1974 17. Ey H: Confusion et dtlire confusoonirique, Etude 24 in Etudes Psychiatriques. Paris, Desclee de Brouwer, pp. 326-368, 1954 18. Marchais P: Les processus psychopathologiques de l’adulte, Paris, Privat, 1981 19. Levin M: Varieties of Disorientation. Journ Men Sci, 102:619-623, 1956 20. Bash KW: Lehrbuch der Allgemainen Psychopathologic. Grundbegriffe und Klinik, Stuttgart, George Thieme, pp. 185-198, 1955 21. Ryle G: The concept of mind. London, Hutchinson, 1948 22. Metzger W: Psychologie (2nd Edition). Darmstadt, Steinkopff, pp. 140-142, 1954 23. Klein E: A Comprehensive Etymological Dictionary of the English Language. Vol. 2. Amsterdam, Elsevier, 1967 24. O.E.D. Oxford English Dictionary. Oxford, Oxford University Press, 1970 25. Mott FW: Arterial degenerations and diseases in Allbutt TC (Ed.) A system of medicine by many writers, Vol. IV, London, McMillan, 1899, pp. 294-344 26. Dupytren Baron de: On nervous delirium, Lancet, 1834, i, 919-923 27. Sutton T: Tracts on Delirium Tremens. . and on the Gout, London, on Peritonitis Thomas Underwood, 1813 28. Berrios GE: Stupor, a conceptual history. Psychological Medicine, 11:677-688, 1981 29. Falret J: Amnesie in Dechambre, A. (Ed.) Dictionnaire Encyclopedique des sciences mtdicales Vol. 3, Paris, Asselin and Masson, 1865, pp. 725-742 30. Winslow F: On obscure diseases of the brain and disorders of the mind, London. John W. Davies, 1861, p. 343 31. Bercherie P: Les Fondements de la clinique, Paris, La Bibliothtque d’Omicar?, 1980 32. Jastrow J: Orientation (Mental) in Baldwin, J.M. (Ed.) Dictionary of Philosophy and Psychology, Vol. 2, New York, McMillan. 1901 33. Wernicke C: Grundriss der Psychiatric, Leipzig, Thieme, 1906
DISORIENTATION
STATES
34. Janet P: Les obsessions et la psychasthenie, Vol. 1, Paris, Alcan, 1919 3.5. Konig, H: Zur Psychopathologic der Paralysis agitans. Archives fur Psychiatric und Nervenkrankheiten, 50:285-305, 1912 36. Jaspers K: General Psychopathology (Translated by Hamilton, M.) Manchester, Manchester University Press 37. Bleuler E: Textbook of Psychiatry. New York, McMillan, 1924 38. Cabaleiro Goas M: Temas Psiquiatricos, Madrid, Paz Montalvo, 1966 39. Strub RL. Black FW: Organic brain syndromes, Philadelphia, FA Davis, 1981 40. Zangwill OL: The amnesic syndrome in Whitty C.W.M. and Zangwill, O.L. (Eds.) Amnesia, 2nd Edition, London, Butterworths. 1977 pp. 104-l 17 41. Hesnard A: Les psychoses et les front&es de la folie, Paris, Flammarion, 1924 42. Gale RM (Ed.): The philosophy of time. A collection of Essays. London, McMillan, 1968 43. Lucas JR: A treatise on time and space. London, Methuen. 1973 44. Goody W: Disorders of orientation in space-time. Brit Journ Psych. 112:661-670, 1966 45. Minkowski E: La schizophrenic. Psydes schizoides et chopathologie des schizophrenes. Paris. Des&e de Brouwer, 1927 46. Lewis A: The experience of time in mental disorder. Proceedings of Royal Society of Medicine, 2.5:15-24, 1932 47. Lehmann HE: Time and psychopathology. Annals New York, Academy of Sciences. 138:798-821. 1967 48. Cohen J: Psychological time. Scientific American. 1964. November. 49. Benton AL. Allen MW van, Fogel ML: Temporal orientation in cerebral disease. Journ Nerv Ment Dis, 139:110-119. 1964 50. Cohen S. Mezey AG: The effect of anxiety on time judgement and time experience in normal persons. Journ Neurology. Neurosurgery Psychiatry, 24:266-268, 1961 5 I. Mezey AG. Cohen SI: The effect of depressive illness on time judgement and time experience. Journ Neourology, Neurosurgery Psychiatry, 24:269-270. 1961 52. Le Guen C: Troubles des conduites temporelles. Encyclopedic Mtdico-Chirurgicale. Psychiatric. Vol. 1 37136 A 10. Paris. Editions Techinques. 1963 53. Sztulman H: Psychometric du temps dans la schizophrenic. Annales Medico-Psychologiques. i:27-38. 1968
489 54. Strub RL. Black FW: The mental status examination in neurology. Philadelphia. FA Davies, 1977 55. Bouchard. R: Sur I’evaluation du temps dans certains troubles mentaux. These de Paris. Vigot f&es Editeurs, 1926 56. McFie J: Psychological testing in clinical neurology. Journ Nerv Ment Dis, 131:383-393. 1960 57. Lipowski ZJ: Delirium, acute brain failure in Man. Illinois, Thomas, 1980 58. Bleuler M: Acute concomitants of Physical Disease. In Benson DF, Blumer D (Eds.): Psychiatric Aspects of Neurological Disease. New York. Grune and Stratton, 1975. pp. 37-61 59. Chedru F, Geschwind N: Disorders of higher cortical functions in acute confusional states. Cortex. 8:395-41 I. 1972 60. Porot M, Planche R: Confusion Mentale. Encyclopedic Medico-Chirurgicale. 37240. A IO, 5 (Psychiatric), Paris, Editions Techniques. 1969 61. Allison RS: The senile brain. a clinical study. London. Edward Arnold. 1962 62. Goody W: Disorders of time sense in Vinken PJ, Bruyn GW (Eds.) Handbook of Clinical Neurology, Vol. 3. Disorders of Higher Nervous Activity, Amsterdam, North Holland. 1969 63. Levin HS, Benton AL: Temporal orientation in patients with brain disease. Applied Neurophysiology. 3856-60, 1975 64. Joslyn D. Hutzell RR: Temporal disorientation in schizophrenic and brain-damaged patients, Amer Journ Psych 136: 1220-1222. 1979 65. Coheen JJ: Disturbances in time discrimination in organic brain disease. Journ Nerv Ment Dis. 112:121-129. 1950 66. Ellen P. Powell E: Timing behaviour after lesions of zona incerta and mammillary body. Science, 141:828-830, 1963 67. Efron R: Temporal perception. aphasia and dej& vu. Brain. 86:403-424. 1963 68. Spiegel EA. Wycis HT. Orchinik C et al: Thalamic chronotaraxis. Amer Journ Psych. 113:97-10.5, 1956 69. Davidson GM: A syndrome of time agnosia. Journ Nerv Ment Dis. 94:336-343. 1941 70. Bouman L. Grtinbaum AA: Eine Storung de Chronognosie und ihre Bedeuting im bettreffenden Symptomenbild. Monatschrift fitt Psychiatric und Neurologie. 73: l-39. 1929 71. Beaudouin H. Bouchard K: Tests d’dvaluation du temps Annales Medico-Psychologiques, i:293-295. 1927
490
72. Freeman AM, Melges FT: Depersonalization and temporal disintegration in acute mental illness. Amer Joum Psych, 134:679-681, 1977 73. McAllister TW: Cognitive functioning in the affective disorders. Comp Psych, 22572-586, 1981 74. Berrios GE: Stupor Revisited. Comp Psych, 22:466-478, 1981 7.5. RCgis E: Precis de Psychiatric, Paris: Octave Doin, 1906 76. Jung CG: The Psychology of Dementia Praecox in The Collected Works, Vol. 3, London, Routledge and Kegan Paul. 77. Bleuler E: Dementia Praecox or the group of the schizophrenias. International Universities Press, New York, 1950 78. Kraepelin E: Dementia Praecox and Paraphrenia. Edinburgh, Livingstone 1919 79. Minkowski E: Bergson’s conceptions as applied to psychopathology. Journ Nerv Ment Dis, 63:553-561, 1926 80. Schilder P: Psychopathology of time. Journ Nerv Ment Dis, 83:530-546, 1936 81. Seeman MV: Time and schizophrenia. Psychiatry, 39:189-195, 1976 82. Garza CO de la, Worchel P: Time and space disorientation in schizophrenics. Journ Abnormal Psychology, 52:191-194, 1956 83. Ciompi L: Uber abnormes Zeiterleben bei einer Schizophrenen. Psychiatria et Neurologia, 142: 100-121, 1961 84. Rabin AT: Time estimation of schizophrenics and non-psychotics. Journ Clin Psychology, 13:88-90, 1957 85. Guertin WH, Rabin AI: Misperception of time in schizophrenia. Psychological Reports, 7:57-58, 1960 86. Goldstone S: The human clock: a framework for the study of healthy and deviant time perception. Annals New York Academy of Science, 138:767-783, 1967 87. Crow TJ, Mitchell WS: Subjective age in chronic schizophrenia: evidence for a subgroup of patients with defective learning capacity? Brit Joum Psych, 126:360-363, 1975 88. Letemendia FJJ, Harris AD: Chlorpromazine and the untreated chronic schizophrenic: a long term therapeutic trial. Brit Journ Psych, 113:950-958, 1967 89. Melges FT, Fougerousse CE: Time, sense, emotions and acute mental illness. Journ Psych Res, 4:127-140, 1966 90. Freeman AM, Melges FT: Temporal disorganization, depersonalization and persecutory ideation in acute mental illness. Amer Journ Psych, 135:123-124, 1978
G. E. BERRIOS
91. Melges FT, Freeman AM: Temporal disorganization and inner-outer confusion in acute mental illness. Amer Joum Psych, 134:874-877, 1977 92. Melges FT, Tinklenberg JR, Deardorff CM et al: Temporal disorganization and delusional-like ideation. Processes induced by Hashish and Alcohol. Arch Gen Psych, 30:855-861, 1974 93. Mercer B, Wapner W, Gardner H et al: A study of confabulation. Arch Neurology, 34~429-433, 1977 94. O’Keefe J, Nadel L: The hippocampus as a cognitive map. Oxford, Clarendon Press, 1978 95. Williams M: Spatial disorientation in senile dementia. Journ Ment Sci, 102:291-299, 1956 96. Ajuriaguerra J de, Richard J, Rodriguez R et al: Quelques aspects de la d&integration des praxies ideomotrices dans les demences de grand age. Cortex, 2:434-462, 1966 97. Semmes J, Weinstein S, Ghent L, et al: Correlates of impaired orientation in personal and extrapersonal space. Brain, 86:747-772, 1963 98. Lezak MD: Neuropsychological assessment. New York, Oxford University Press, 1977 99. Badal J: Contribution a l’etude des &cites psychiques: alexie, agraphie, hemianopsie inferieure, troubles du sens de I’espace. Archives Ophtalmologiques, 8:97-l 17, 1888 100. Meyer 0: Ein und doppelseitige homonyme Hemianopsie mit Orientierungsst6rungen. Monatschrift fur Psychiatric und Neurologie, 8:440-456, 1900 101. Balint R: Seelenlahmung des “schauens”. optische ataxie, raumliche Storung der Aufmersamkeit. Monatschrift fur Psychiatrie und Neurologie, 25:51-81, 1909 102. Holmes G: Disturbances of visual orientation. Brit Joum Ophth, 2449-469; 506-516, 1918 103. Taylor F, Krlupl: Psychopathology, its causes and symptoms. London, Butterworths, 1966 104. Levin M: Spatial disorientation in delirium. Amer Journ Psych, 113:174-175, 1956a 105. McCallum WAG: Capgras syndrome with an organic basis. Brit Journ Psych, 123:639-642, 1973 106. Benson FD, Gardner H, Meadows JC: Reduplicative paramnesia. Neurology, 26:147-151, 1976 107. Scharfetter C: Allgemeine Psychopathologie, Stuttgart, Georg. Thieme, 1976
DISORIENTATION
STATES
108. Rabins PV, Folstein MF: Delirium and dementia: Diagnostic criteria and fatality rates. Brit Journ Psych, 140:49-153, 1982 109. Lishmann WA: Organic Psychiatry. Oxford, Blackwells, 1978 110. Heathfield KWG, Croft PB, Swash M: The syndrome of transient global amnesia. Brain. 96729-735, 1973
491
111. Fisher CM, Adams RD: Transient Global Amnesia. Acta Neurologica Scandinavica, Supplement 9, pp. 7-83, 1964 112. Janet P: Etat mental des HystCriques. Rueff, Paris, pp. 79-121 113. Ballinger BR, Reid AH, Heather. BB: Cluster Analysis of symptoms in elderly demented patients. Brit Journ Psych, 140:257-X2. 1982