Self-consciousness and Alzheimer''s disease

OBJECTIVES: To propose a neuropsychological study of the various aspects of self-consciousness (SC) in Alzheimer's disease. METHODS: Forty-five patients with probable mild or moderate AD were included in the study. Severity of their dementia was assessed by the Mini Mental State (MMS). Fourteen questions were prepared to evaluate SC. RESULTS: No significant correlations were found between SC score and educational level, age, and duration of disease. A significant correlation was found between SC score and the severity of dementia, whereas frontal disturbances were just short of the significance threshold. The various aspects of SC were not impaired to the same degree. The most disturbed ones were awareness of cognitive deficiencies, moral judgements and prospective memory. The least disturbed aspects were awareness of identity and of mental representation of the body. Items relating to anosognosia and moral judgements were significantly correlated with the MMS score, whereas affective state, body representation disorders, prospective memory, and capacities for introspection were not related to the severity of the dementia. Consciousness of identity was sound, regardless of MMS score. CONCLUSIONS: AD clearly induces an heterogeneous impairment of SC. SC requires a convergence of many neural networks. In AD, neuronal alterations involve many cortical areas and information sent to the associative frontal cortex from memory, language and visuospatial areas is lacking or disturbed. Thus, the sequential order of successive stimuli cannot be maintained by the heteromodal associative cortex (dorsal convexity of the prefrontal cortex), and the supramodal associative cortex (located rostrally in the frontal lobes) is unable to provide reliable monitoring and assessment of simultaneous neural cognitive networks carrying insufficient and inadequate input. The core deficiency in AD patients might be impaired SC equated with the disability to maintain sequential and simultaneous "attention to life". The Self-Consciousness Questionnaire, a clinical scale providing multidimensional measurement, indicates that different aspects of consciousness are not correlated with overall cognitive deficiency as determined by the MMSE.     

Aging effect on frontal lobe function-evaluation by the new modified Wisconsin Card Sorting Test

New Modified Wisconsin Card Sorting Test (WCST) was administered to ninety-five individuals to assess the effects of age on frontal lobe functions. The correlations between ages and scores were evaluated in the following five subgroups which were classified into whole subjects (TOL, n = 95), normals and patients who were neurologically diagnosed as only having cervical spondylosis (NOR, n = 20), individuals whose age-corrected total intelligence quotients (TIQ) by the Wechsler Adult Intelligence Scale were higher than or equal to 100 (HIQ, n = 30), individuals whose TIQ were less than 100 (LIQ, n = 27), and individuals whose Mini-Mental State Examination scores were full (MMS, n = 28). Scores of the WCST including Categories Achieved, Total Errors, Difficulty of Maintaining Set and Perseveration were significantly correlated to ages in four groups such as TOL, NOR, HIQ, and MMS. The correlation of WCST's scores of the four groups indicated almost the same tendency. Some subcategories of the WCST, indicating perservation which were characteristic signs of the frontal lobe dysfunction correlated with ages in these four groups. The groups indicating NOR, HIQ, and MMS were thought to be regarded as being normal controls. And, the scores of Mini-Mental State Examination were not correlated with ages. So, the WCST scores of the MMS group were no thought to be effected by the age-related decline of intelligence. The results might suggest that the age-related decline of the frontal lobe function precedes that of intelligence.     

Neural correlates of anosognosia for cognitive impairment in Alzheimer's disease

We explored the neural substrate of anosognosia for cognitive impairment in Alzheimer's disease (AD). Two hundred nine patients with mild to moderate dementia and their caregivers assessed patients' cognitive impairment by answering a structured questionnaire. Subjects rated 13 cognitive domains as not impaired or associated with mild, moderate, severe, or very severe difficulties, and a sum score was calculated. Two measures of anosognosia were derived. A patient's self assessment, unconfounded by objective measurements of cognitive deficits such as dementia severity and episodic memory impairment, provided an estimate of impaired self-evaluative judgment about cognition in AD. Impaired self-evaluation was related to a decrease in brain metabolism measured with 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in orbital prefrontal cortex and in medial temporal structures. In a cognitive model of anosognosia, medial temporal dysfunction might impair a comparison mechanism between current information on cognition and personal knowledge. Hypoactivity in orbitofrontal cortex may not allow AD patients to update the qualitative judgment associated with their impaired cognitive abilities. Caregivers perceived greater cognitive impairments than patients did. The discrepancy score between caregiver's and patient's evaluations, an other measure of anosognosia, was negatively related to metabolic activity located in the temporoparietal junction, consistent with an impairment of self-referential processes and perspective taking in AD.     

Cognitive and functional neuroimaging correlate for anosognosia in mild cognitive impairment and Alzheimer's disease

OBJECTIVES: To investigate the correlation between anosognosia and behavioural symptoms, performance on executive tests, and frontal cortex regional cerebral blood flow (rCBF) in patients with 'amnestic mild cognitive impairment' (MCI) and mild Alzheimer's disease (AD). METHODS: From a prospective Memory Clinic cohort including consecutively referred patients, age 60 years or above, and with MMSE score 20 or above, 36 patients with AD and 30 with MCI were included in this study. Anosognosia was assessed using a categorical scale and discrepancy scores between patients' and relatives' reports on a 20-item Memory Questionnaire (MQ). Behavioural symptoms were assessed with Frontal Behavioural Inventory (FBI). Executive functions were examined with a range of neuropsychological tests. Tc99m-HMPAO SPECT was obtained in an unselected sample of 55 of the 66 patients, and rCBF was analysed in six cortical frontal regions. RESULTS: Insight was equally impaired in the two patient groups. A significant correlation was found between impaired awareness and dementia severity (MMSE). Discrepancy-scores on the MQ were significantly correlated to scores on FBI and to rCBF in the right inferior frontal gyrus, but not to executive tests. The groups classified by the categorical ratings 'full', 'shallow' and 'no' awareness were not characterized by differences in behavioural symptoms, executive performance or frontal rCBF. CONCLUSIONS: Impaired awareness is associated with behavioural symptoms and may reflect functional impairment in the right inferior frontal cortex.     

Symptoms underlying unawareness of memory impairment in patients with mild Alzheimer's disease

Patients with Alzheimer's disease (AD) are often unaware of their cognitive impairment. This unawareness might have a multifactorial etiology, including impairment of cognitive domains and psychiatric symptoms. We conducted this study to determine the factors underlying unawareness of memory impairment (UMI) in patients with AD. In 103 patients with mild AD, the UMI was quantified as the difference between the patient's self-rating and the rating of the patient's caregiver on a standardized memory questionnaire system, the Everyday Memory Checklist. We then examined the relationships between UMI and memory, attention, language, visuospatial/constructive perception, frontal lobe function, and psychiatric symptoms. UMI was positively associated with memory impairment and delusions when effects of age, sex, and education were partialled out, suggesting that these symptoms are involved in the formation of UMI in the patients. Thus, existing treatments for memory impairment and delusions may be beneficial for increasing the awareness of mild AD patients of their cognitive impairment.     

Mnemonic anosognosia in Alzheimer's disease: a test of Agnew and Morris (1998)

Agnew and Morris [Agnew, S. K. & Morris, R. G. (1998). The heterogeneity of anosognosia for memory impairment in Alzheimer's disease: A review of the literature and a proposed model. Aging and Mental Health, 2, 9-15] model of awareness for memory functioning has attempted to account for the variance of anosognosia exhibited within the Alzheimer's disease (AD) population. There has been tentative evidence to suggest that the mnemonic anosognosia sub-type, proposed by this model, is common within the early stages of AD. However, this study is the first directly to test the model. Eighteen older adults with early AD and 18 healthy older adults were recruited. Awareness of memory functioning was monitored using patient-performance measures of "task specific" awareness; a measure of global memory awareness; and a patient-informant measure. The stability of participants' awareness was measured across three word recall lists and after a 20-min delay. Results suggested that, whilst the participants with early AD were less aware of their memory ability than the healthy older adults, they were able to improve their awareness following exposure to a memory task. Furthermore, the improvements in awareness were largely retained after the delay period. These findings are discussed in relation to Agnew and Morris [Agnew, S. K. & Morris, R. G. (1998). The heterogeneity of anosognosia for memory impairment in Alzheimer's disease: A review of the literature and a proposed model. Aging and Mental Health, 2, 9-15] model of mnemonic anosognosia and to current thinking about autobiographical memory.     

Metamemory in Alzheimer's disease

Alois Alzheimer's first publication describes his patient's inability to be aware of her condition. One hundred years later, whether or not Alzheimer's disease (AD) patients show impaired awareness of their memory deficits is still of debate. This review makes a novel contribution, arguing that the ideal empirical tool to assess this question is the metamemory framework. The fact that the metamemory framework offers models of healthy memory and metamemory function and ready-developed measures mapped onto theoretical constructs, means that it is a useful paradigm to explore the question of memory awareness. The review focuses on two as yet separate approaches: the neuropsychological models of anosognosia as well as the metamemory framework. Metamemory constructs and measures are used to evaluate Alzheimer's patients' awareness of their memory difficulties by relating the main findings to the existing neuropsychological model of anosognosia. With this approach, only very specific deficits in awareness are found: a failure to update self-beliefs, and a deficit in monitoring episodic memory, possibly related to a deficit in effortful, conscious control processes. This review also considers how the exploration of the neural correlates of metamemory can help to draw novel hypotheses on the brain regions implicated in anosognosia in AD.     

精神分裂症患者认知功能与精神症状相关性研究

目的：探讨精神分裂症患者认知功能与精神症状的相关性。方法：对40例精神分裂症患者于治疗前、治疗12周末分别进行韦氏成人智力量表（WAIS-R）、韦氏记忆量表（WMS）、H—R神经心理成套测验（HRB）中的连线测验A、威斯康星卡片分类测验（WCST）及言语流利性测验及简明精神病评定量表（BPRS）评定。结果：治疗前焦虑抑郁因子分与总记忆商数（MQ）分显著相关,迟滞因子分与WCST完成类别数、智力显著相关;治疗12周末焦虑抑郁因子分与总智商（IQ）显著相关,迟滞因子分与WCST持续反应数、言语IQ、操作IQ显著相关,猜疑因子分与WCST持续反应数显著相关。结论：精神分裂症患者部分认知功能与精神症状显著相关。     

Regional cerebral blood flow measured by99mTc-HMPAO SPECT differs in subgroups of Alzheimer's disease

Summary Alzheimer's disease (AD) is a heterogeneous entity. Identifying AD subtypes might have impact in patients' response to different treatment strategies. We designed a study to examine regional cerebral blood flow (rCBF) in AD subtypes. To identify AD subtypes, we performed a cluster analysis including performance on memory, language, visuospatial, praxis, and executive functions. The rCBF measured by^99mTc-HMPAO SPECT was referred to the cerebellum. We examined 35 patients fulfilling the NINCDS-ADRDA criteria of probable AD and 13 age and sex-matched healthy cognitively intact controls. AD patients were at the early stage of the disease, their mean Mini-Mental Status (MMS) score (S.D.) was 22.5 (3.6). The cluster analysis revealed two AD subgroups: AD1 (N=12) and AD2 (N=23). The subgroups did not differ in age, sex, or global clinical severity as assessed by MMS and Brief Cognitive Rating Scale (BCRS). Both subgroups had equally impaired memory. The AD2 group was inferior to the AD1 group on verbal, visuospatial, praxic, and executive functions. The AD1 group showed reduced rCBF ratios in the temporal and parietal cortices and the amygdala compared to controls. The AD2 group differed from controls in the rCBF ratios of frontal, temporal, parietal, occipital, basal ganglia, and amygdaloid regions bilateral and from AD1 in the rCBF ratios of frontal and temporal cortices. In AD patients, the rCBF ratios did not correlate with MMS or BCRS scores. In contrast, several significant correlations were found between decreases rCBF ratios and impairment of memory and other cognitive functions. In conclusion, a cluster analysis on neuropsychological test performance identified two AD subgroups that differed on the neuropsychological profile and on the rCBF in spite of similar global clinical severity.     

Primary and secondary anosognosia for memory impairment in patients with Alzheimer's disease

The neuropsychology of anosognosia for memory impairment in Alzheimer's disease (AD) was examined in 92 AD patients and 92 case matched individuals for comparison, using three quantitative methods of assessment: Experimenter Rating Scale (ERS), Objective Judgement Discrepancy (OJD) and Subjective-Rating Discrepancy (SRD). The OJD showed significant domain specific correlations with memory functioning as well as a significant correlation with susceptibility to intrusional errors. Memory or executive dysfunction may affect the immediate ability to judge cognitive performance in a domain specific manner (secondary anosognosia). Longer-term awareness of cognitive deficit appears less influenced by impaired basic cognitive functions, than by the decline of metacognitive function (primary anosognosia).     

原发性失眠症患者认知功能的研究

目的:探讨原发性失眠症患者认知功能损害的特点。方法:采用神经心理测验包括韦氏记忆(数字累加、视觉再认、视觉再生、联想学习)、数字广度、数字划消、连线测验和威斯康辛卡片分类测验(WCST)分别对35例原发性失眠症患者(失眠组)和30名健康对照者(正常对照组)进行注意力、记忆力、执行功能等方面的测评;同时应用匹兹堡睡眠质量指数量表(PSQI)、抑郁自评量表(SDS)、焦虑自评量表(SAS)分别评定失眠及伴随的焦虑、抑郁症状的严重程度。结果:失眠组在数字累加、视觉再认、视觉再生、联想学习、数字广度测验的数字倒背、数字划消测验中的注意力失误率、连线测验B及BA完成时间和WCST测验的各项成绩(除正确应答数外)均明显差于正常对照组(F=4.646~28.224,P0.05或P0.01)。失眠组数字累加分与病程呈负相关(r=-0.558,P=0.001);联想学习分与PSQI评分呈负相关(r=-0.405,P=0.019);连线测验B-A时间与病程呈正相关(r=0.405,P=0.019);WCST持续错误百分比与SDS分呈正相关(r=0.309,P=0.045)。结论:原发性失眠症患者存在广泛认知功能损害,其病程、失眠程度以及伴随的焦虑抑郁情绪是导致认知功能损害的影响因素。     

A dissociation in the relation between memory tasks and frontal lobe tests in the normal elderly

In this study a group of elderly subjects were examined on three tests of frontal lobe function. Two of these tests, FAS word fluency and the Alternate Uses Test, were considered tests of spontaneous flexibility, as defined by Eslinger and Grattan [Neuropsychologia 31, 17–28, 1993]. The third, the modified Wisconsin Card Sorting Test (WCST), is considered a test of reactive flexibility. Performance on two tests of memory, release from proactive interference (PI) and a matched recall and recognition test was also measured. The elderly were shown to be impaired on all tests when compared with young controls. Analysis revealed that release from proactive interference was significantly correlated with performance on alternative uses but not WCST while the size of subjects' discrepancy between recall and recognition correlated strongly with WCST but not with Alternate Uses. In addition there was a strong correlation between the two measures of spontaneous flexibility but these measures did not correlate with WCST. Performance on the two measures of memory was also uncorrelated. The data indicate that the pattern of frontal deterioration in the elderly does not comprise a single deficit and, furthermore, that the relationship between frontal dysfunction and normal age-related memory loss is not undimensional.     

Memory impairment differs in frontotemporal dementia and Alzheimer's disease

The aim of this study was to assess short-term and long-term explicit memory and implicit memory in frontotemporal dementia (FTD; frontal variant) and to compare FTD and Alzheimer's disease (AD) patients with similar severity of dementia. Fifteen FTD patients [mean age: 68 years; Mini-Mental State (MMS): 24], 30 probable AD patients (mean age: 72 years; MMS: 23) and 12 healthy subjects participated in the study. The three groups were comparable in terms of gender and educational level. Short-term memory was assessed with the digit span and Corsi block-tapping tests. Explicit verbal memory was assessed with the Grober and Buschke test, and implicit memory with a verbal priming task and a fragmented picture test. FTD patients demonstrated a genuine memory deficit with impaired digit span, encoding deficit and retrieval strategy difficulties, but preserved implicit verbal and visual priming. Memory patterns differed in AD and FTD: short-term memory and free recall were similarly decreased in FTD and AD but cues provided more benefit to FTD than to AD; encoding was more impaired and the forgetting rate was faster in AD than in FTD; priming was lower in AD than in FTD. AD patients with clinical and imaging frontal lobe dysfunction tended to have lower memory performance and to differ even more from FTD patients than AD patients without frontal lobe dysfunction.     

A study of stereotypic behaviours in Alzheimer's disease and frontal and temporal variant frontotemporal dementia

OBJECTIVE: To document the prevalence and pattern of stereotypic behaviour in patients with Alzheimer's dementia and frontal and temporal variants of frontotemporal dementia. Secondly, to examine the relationship between stereotypic and other neuropsychiatric behaviours. METHODS: Patients with the following were studied; Alzheimer's disease (n=28), frontal variant frontotemporal dementia (fvFTD, n=18), and semantic dementia-the temporal lobe variant of FTD (n=13). All patients were assessed using the Neuropsychiatric Inventory (NPI), the Mini-Mental State Examination, Addenbrooke's Cognitive Examination, and the Clinical Dementia Rating scale. Patients were also rated on the newly devised Stereotypic and Ritualistic Behaviour (SRB) subscale, which was designed as an addendum to the NPI. RESULTS: There was no significant difference across diagnostic groups in terms of age, sex, or severity of cognitive deficits. The overall NPI was significantly higher in patients with fvFTD compared with the other two groups, but fvFTD and semantic dementia showed a similar, and significantly increased, prevalence of stereotypic behaviours on the SRB subscale. Within the FTD group as a whole these behaviours were more likely to be complex, whereas in Alzheimer's disease, when present, such behaviours tended to be more simple stereotypies or stimulus bound repetitive behaviours. Stereotypic behaviours were not correlated with either disease severity or the extent of cognitive impairment in the fvFTD group, but were in the other two diagnostic groups. CONCLUSION: Complex stereotypic behaviours are a core feature of the dementing syndrome in FTD and may reflect early and specific deficits in orbitofrontal circuitry and basal ganglia involvement.     

Cognitive deficits in obsessive-compulsive disorder on tests of frontal lobe functions

Individuals with obsessive-compulsive disorder (OCD) display frontal lobe deficits, but there are inconsistencies between various tests of frontal lobe functions and between the results from different studies. The objective of this work was to characterize frontal lobe dysfunctions in OCD patients. Fifteen patients and 17 control subjects matched for age, sex and intelligence were tested on classic tests of frontal lobe functions [Wisconsin Card Sorting Test (WCST) and tests of fluency], a smell identification test and one computerized test: the Intra/Extra Dimension test. The Intra/Extra Dimension test showed a significant difference between the two groups in reversal of response. The test of Figural fluency showed a significant difference between the two groups in numbers of produced figures. There were no differences on the WCST, verbal fluency and the smell identification test.     

Two dimensions of anosognosia in patients with Alzheimer's disease: reliability and validity of the Japanese version of the Anosognosia Questionnaire for Dementia (AQ-D)

Although a number of studies have examined anosognosia of cognitive deficits in patients with Alzheimer's disease (AD), not much is known about the anosognosia of behavioral symptoms in AD. The aims of the present study were to establish a Japanese version of the Anosognosia Questionnaire-Dementia (AQ-D) and to examine its factor structure, reliability and validity, and to identify the effects of various variables on the AQ-D. Factor structure, internal consistency, test-retest reliability and concurrent validity of the Japanese version of the AQ-D were analyzed. Multiple regression was then done using the results of the AQ-D as dependent variables and entering all relevant predictor variables. Both the internal consistency and the test-retest reliability of the AQ-D were excellent. Factor analysis indicated four factors: anosognosia of basic and instrumental activities of daily living; that of episodic memory and orientation; that of disinhibited behaviors; and that of apathy and depression. The first two factors were regarded as anosognosia of cognitive deficits and were associated with Mini-Mental State Examination scores, while the latter two factors were regarded as anosognosia of behavioral symptoms and were associated with the Neuropsychiatric Inventory (NPI) score. A dissociation between the two domains of anosognosia was confirmed, namely of cognitive deficits and of behavioral symptoms using the Japanese version of the AQ-D. The knowledge that various factors may have different effects on different domains of anosognosia in patients with AD may serve as useful information for clinicians assessing anosognosia in AD.     

Patient versus informant reported quality of life in the earliest phases of Alzheimer's disease

OBJECTIVES: The study investigated if patient and informant reported Quality of Life (QoL) differed in early Alzheimer's disease (AD). In addition, we examined whether anosognosia had an impact on the agreement between patient and informant ratings of QoL and whether anosognosia, dementia severity, depression and behavioural symptoms were significantly correlated to QoL in early AD. METHODS: From a prospective research program including newly referred patients (age >60 years and MMSE > or = 20), 48 patients with very early AD were included. QoL was assessed using the QoL-AD and EQ-5D scales. Anosognosia was rated on a categorical scale by an examiner. MMSE, Geriatric Depression Scale, Danish Adult Reading Test and Frontal Behavioural Inventory were also administered. RESULTS: On most QoL measures patients rated their QoL higher than their informants. Anosognosia was not associated with QoL but significantly with an inverse impact on the agreement between patient and informant ratings of QoL. Self-reported QoL was significantly correlated to depression but not to age, dementia severity, behavioural symptoms or memory impairment. Informant ratings of QoL were significantly correlated to behavioural symptoms and informant ratings on the EQ-5D Visual Analogue Scale were significantly correlated to patient reported depression. CONCLUSION: Patients with early AD generally reported higher QoL than their informants. This disagreement was associated with the presence of anosognosia. Self-reported QoL did not correlate with the MMSE score. Behavioural changes and depressive symptoms may be associated with low QoL.     

The effects of clozapine on cognitive function and regional cerebral blood flow in the negative symptom profile schizophrenia

OBJECTIVE: Cognitive function and regional cerebral blood flow (rCBF) were studied in negative symptom profile schizophrenic patients by using WCST and SPECT. METHODS: Twenty-one schizophrenic patients who matched the criteria of Andreason's negative symptom profile received SPECT and WCST, and then were treated with clozapine for 8 consecutive weeks. There were 28 and 12 normal subjects as the control groups of WCST and SPECT, respectively. RESULTS: Compared with controls, significantly poorer performance on total trials of category (TT), persevering errors (PE), and non-persevering errors (NPE) of WCST were found in schizophrenia (p < 0.05). The total score of the scale for assessment negative symptoms (SANS) was significantly related with poor TT (r = 0.45, p < 0.01) and PE performance (r = 0.45, p < 0.01). The poor TT, PE, and NPE tasks of WCST and SANS scores in the negative schizophrenic patients were significantly improved through clozapine treatment (p < 0.05). The schizophrenic patients had a significantly lower rCBF in bilateral frontal and temporal lobes and lower change rate of rCBF in bilateral frontal lobes during WCST compared to normal controls (p < 0.05). CONCLUSIONS: Negative symptom profile schizophrenia has cognitive deficits and lower rCBF in bilateral frontal and temporal lobes, which suggests that negative symptom profile schizophrenic patients have hypofrontality. Clozapine can improve negative symptoms and improve cognitive dysfunction, although it cannot improve reduced rCBF in the frontal lobes.     

Several factors to distinguish anosognosia from denial after a brain injury

This Article deals with the question of ignorance after a serious brain injury. The main purpose of this research is to present some factors that are critical for the differential diagnosis of anosognosia (organic etiology) and denial (psychological etiology) in order to improve the rehabilitation strategies of brain injuried population. In the present work we report the case study of MG (Havet-Thomassin, 2000). MG is a 32 Year old right handed man who has undergone a severe brain injury after a car accident. Neuropsychological approach of ignorance is mainly landed from questionnaire assessment of deficit. The QAM (Questionnaire of self assessment of memory performance, Van der Linden et al., 1988) and the PCRS (Patient Competency Rating Scale, Roueche et Fordyce, 1982) where used for the neuropsychological assessment of anosognosia. The neuropsychological baseline was obtained from classical executive tasks (TMT, Stroop, TOL, WCST) in order to show a possible link between executive dysfunction and anosognosia. The results point several cognitive impairments (attention, memory, executive functions) and an inadaptated behavior associated to an important anosognosia particularly at the beginning of the hospitalization (absence of self-criticism and bad compliance to rehabilitation). Furthermore, the patient was interviewed regularly in order to better dissociate denial from anosognosia. This clinical approach facilitated the understanding of the inherent psychological dynamic of MG which was particularly exacerbated by the frontal desinhibition. Characterization of identity profile and homosexuality are of great interest in this case as they were strongly reactivated by the traumatism. The brain injury leads to the reorganization of the whole identity of MG which seems no more unified but divided. Reality principle was responsible for too much anxiety which became probably acute by a narcissistic flaw. Therefore it encourages the subject to deny in order to guarantee to himself a psychic balance. Thus, at the beginning, MG denies totally his homosexuality and then, he admits it progressively declaring that it has disappeared since the accident. He progressively developed an excessive aggressiveness in regard of the homosexual community insinuated unconsciously from his discourse his feminine and passive position (slips, denegations). This denial is critical for MG's psychic integrity and that is why the priority should not be its suppression. From this work, we consider that anosognosia remains independent of the patient's will, but still linked to the dysexecutive syndrom. In opposite, the denial corresponds to defensive and strategic processes devoted to the subject adaptation to an agonizing situation. Even if those two clinical facts appear similar, it is possible to propose several factors in order to distinguish anosognosia from denial: 1) anosognosia and denial don't seem to turn on the same elements; 2) anosognosia seems to be more transitional on the contrary of the denial which appears to be more chronic; 3) behavior reaction in the case of anosognosia seems to be partially different from the denial; 4) as compared to anosognosia, denial appears less stable and more uncertain depending on the psychic cost. In conclusion, distinction between anosognosia and denial would allow the clinical psychologist to propose a more adaptated therapy for the patient. Denial must be taken in a dynamic perspective and not as a direct negative consequence of the cerebral injury. In such situation, the priority is not to suppress denial but rather to consider it is the way the subject should face laborious situations imposed by the reality.