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 dis- orientation-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 con- nected two views have developed. The unitary hypothesis states that all ori- entation 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 symp- tom. 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 con- ceptual viewpoints and suggests a model for the analysis of global disorien- tation 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

From Depurtment of Psychiatry, Uni\lersity of Cambridge. Cambridge, England

G. E. Berrios, MA; D.Phil. Sci. (Oxon): MD: FRCPsych.. Uni\,rrsity Lecturer and Con.crc~ta~~t. Department of Psychiutry. University of Cambridge. Cambridge. England

Address reprint requests to G. E. Berrios, MA: D.Phil. Sci. (Oxon): MD: FRCPsych.. lJni\,er.\it>

Lecturer and Consultant, Department of Psychiatp. Uniwrsity of‘ Cumhridge. Addenbrooke’c

Hospital (Level 4). Hills Road, Cambridge. England

0 1982 by Grune & Stratton. Inc. OOlO-44041821230510010$1.00I0

Comprehensive Psychiatry, Vol. 23, No. 5 (SeptJOct.1, 1982 479

480 G. E. BERRIOS

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 ref- erence system. “Double orientation” will describe the clinical situation in which the subject may be orientated, simultaneously or alternatively, in re- lation 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 ref- erence 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 arte- riosclerosis. 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 (per- sonal 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: am- nesic, delusional, apathetic and clouded.36 Bleuler drew attention to the phe- nomenon 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 tem- porary disturbance of consciousness;7,38.39 that of Korsakoff’s states as stem- ming 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 genera142,43 and at a clinical leve1.44,45 Time

DISORIENTATION STATES 481

disorientation has been described in association with most psychiatric con- ditions;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 per- ception 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 sys- tems. 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 orien- tation.lh.‘x.‘”

Verbal orientation is tested by asking standard questions which assess syn- chronization to different reckoning systems;‘4 incorrect answers beyond cer- tain 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 “repro- duce” 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~“8 and 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 dis- orientation63,h4 and so do patients with diffuse cortical disease.6s In these cases the parsimonious explanation is that time disorientation may result from mem- ory, 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

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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 syn- drome69 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 infec- tion; 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 sit- uations 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 con- sciouness” (p. 24).

Bouchardss,” described shortening (Raccourcissement) of experienced du- ration in melancholia, prolongation (allongement) in mania and variations in either direction in emotional states. Cohen and Mezey” also found that Mauds- ley Hospital doctors under- or over-estimated time when subjected to a stress- ful situation (speaking in public); the authors speculated that the altered responses might have been mediated by depersonalization experiences. De- personalization (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 abil- ity to produce time remained unimpaired. Lehmann4’ also found that 14 de- pressive 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 im- pairment 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 de- mentia 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 phar- macotherapy 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 defi- nitional 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 pres- ence 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 (“schizo- chronic”) 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

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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 persecu- tory 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 dis- orientated 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 un- familiar for the familiar.” Porot and Planche6’ consider “temporospatial dis- orientation” 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 clin- ical 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-com- plexes 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 disor- ders seem to be distinguished, according to whether disorientation results from cortica1”,‘5.97 or subcortical pathology (e.g. hippocampus and its connec- tions).94

This notwithstanding psychiatric and neuropsychological usage are some- times 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 atten- tion.38,59

DISORIENTATION STATES 485

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 ex- perienced 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”~“‘4 occasionally they even believe that a close relative has been replaced by one impostor.‘“’ This be- havioural 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 de- fect .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 dis- orders 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 phantastica”. Thirdly, there is the group of patients suffering from organic

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mental disorders. Confused personal disorientation in the context of chronic brain disease carries a bad prognosis,“’ it is always accompanied by spatio- temporal disorientation and may develop insidiously with the episodes of disorientation becoming progressively longer until the patient’s identity be- comes 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.9X1’2 T.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 cli- nician; clinico-pathological correlations are not available concerning its inci- dence, types, diagnostic, and prognostic value.

Psychiatric disorientation is not uncommon amongst general hospital pa- tients. 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 psy- chiatric disorientations. Orientation can be tested by asking the patient a number of standard questions or by observing his behaviour. These two meth- ods 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

I r I

I Conscious Non-consci.ous

(speech) (Eehaviour) I

PUBLIC Ri'i.'FElj.ENCE

SYSTEM

Partial

J

Totzl 1

\

Loss without Substitution Substitution Substitution

1 II-----If- 1

Double

/ I

False

’ I Disorientation

Orientation Orientation I

Functional 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 him- self simultaneously or alternatively in relation to both systems; false orien- tation 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 information- processing function accompainies the delusional states.

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