NEUROPSYCHOLOGICAL REHABILITATION

2007, 17 (1), 34 – 52

Topographical disorientation: Towards an integrated

framework for assessment

Ruth Brunsdon1, Lyndsey Nickels2, and Max Coltheart2

1
Developmental Cognitive Neuropsychology Research Unit, Macquarie Centre
for Cognitive Science, Macquarie University, Sydney, and Rehabilitation
Department, Children’s Hospital at Westmead, Sydney, Australia
2
Macquarie Centre for Cognitive Science, Macquarie University, Sydney,
Australia

Topographical disorientation, the inability to find one’s way in large-scale

environments, is a relatively common disorder. However, there are relatively
few cognitive neuropsychological studies that investigate the nature of topogra-
phical cognition. Theoretical progress has been hindered by a number of factors
including: terminological confusion; lack of theoretically driven assessment;
the use of broad classifications for the nature of underlying impairments; and
an ongoing failure to examine topographical skills in real-life settings. As a
result, there is currently no well-established or widely accepted theoretical
framework encompassing all aspects of this multifaceted area of cognition. In
addition, there is a relative paucity of published case studies that include a com-
prehensive, theoretically based assessment of topographical disorientation, and
treatment of the disorder has received virtually no formal investigation (with
the exception of Davis & Coltheart, 1999). Thus, the current paper focuses on
the development of a broad framework for understanding topographical cognition
that integrates a number of recent theories of topographical orientation and mental
imagery (Farah, 1984; Kosslyn, 1980; Riddoch & Humphreys, 1989). The aim of
the paper is to present a preliminary framework that can be used as a basis for
further refinement and development of theoretical proposals, and be employed
by clinicians as a starting point for assessment planning.

Correspondence should be sent to Ruth Brunsdon, Rehabilitation Department, Children’s

Hospital at Westmead, Locked bag 4001, Westmead, NSW, 2145, Sydney, Australia.
Tel: þ61 2 98452804, Fax: þ61 2 98450685, E-mail: ruthb2@chw.edu.au
Ruth Brunsdon was supported by a Department of Education, Science and Training
Australian Post Graduate Award and Lyndsey Nickels by an Australian Research Council
QEII Fellowship during the preparation of this paper.

# 2007 Psychology Press, an imprint of the Taylor & Francis Group, an informa business
http://www.psypress.com/neurorehab DOI:10.1080/09602010500505021
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 35

INTRODUCTION
Topographical orientation refers to the ability of individuals to find their way
from one location to another in large-scale environments such as the home, work-
place or neighbourhood. A disorder of topographical orientation will be referred
to as “topographical disorientation” (or TD) in this paper and refers to individuals
who are unable to navigate or find their way around large-scale environments in a
normal manner. This definition is all encompassing. However, as will be dis-
cussed later topographical disorientation (TD) is a multifaceted and complex
disorder that can arise from a number of different underlying impairments.
Topographical disorientation is relatively common in adults with acquired
brain injury or dementia. It often occurs as part of a global delirium, dementia
or amnesia but can also occur as a more specific cognitive disorder (e.g.,
Davis & Coltheart, 1999; della Rocchetta, Cipolotti, & Warrington, 1996;
Landis, Cummings, Benson, & Palmer, 1986; Suzuki, Yamadori, Hayakawa,
& Fujii, 1998). There have been over 100 years of confusion in the research
literature regarding the exact nature of TD which has been perpetuated by
terminological confusion (for review papers, see Barrash, 1998 or Farrell,
1996). Theoretical progress has been slow with many published studies provid-
ing no more than a general description of patients’ topographical disorientation
and/or associated neuropsychological impairments and/or neuroanatomical
correlates (e.g., Botez-Marquard & Botez, 1992; Cogan, 1979; De Renzi,
Faglioni, & Villa, 1977; Kase et al., 1977; Landis et al., 1986; Mazzoni, Del
Torto, Vista, & Maretti, 1993; Paterson & Zangwill, 1945).
Relatively few studies have investigated the nature of topographical cog-
nition itself. One reason for this may relate to the fundamental complexity
of topographical cognition. In addition, TD rarely occurs as an isolated
disorder, and commonly occurring comorbid deficits (such as visual field
loss, visual agnosia, prosopagnosia, visuo-spatial disturbance, visual
memory impairments and/or constructional difficulties) can cloud underlying
cognitive dissociations (e.g., Benton, 1969; Botez- Marquard & Botez, 1992;
Clarke, Assal, & De Tribolet, 1993; Cogan, 1979; DeRenzi, 1982; Katayama,
Takahashi, Ogawara, & Hattori, 1999; Paterson & Zangwill, 1945). Perhaps
the most significant reason, however, relates to limitations in assessment of
TD. For the most part, assessment has lacked theoretical structure, has
been inconsistent across studies, and has failed to employ functionally
relevant assessment methods.

TOPOGRAPHICAL ORIENTATION AND COGNITIVE

NEUROPSYCHOLOGY
A review of the literature provides considerable evidence that normal topo-
graphical orientation is a complex process that involves an integration of a
36 BRUNSDON, NICKELS, COLTHEART

number of relatively independent cognitive functions such as visual percep-

tion and recognition, spatial processing, memory, and imagery. While it
seems a perfect candidate, there has been a marked lack of cognitive neuro-
psychological research investigating the disorder of TD. There is no reason to
suspect that topographical orientation differs from other visual and perceptual
skills in the degree to which it is amenable to explanation within a cognitive
neuropsychological framework (i.e., through an interconnected system of
dissociable processing modules). However, at this stage there is no widely
accepted cognitive theoretical framework.
The remainder of this paper will therefore focus on the development of a
preliminary framework of topographical cognition with the aim of providing
a basic guide for comprehensive clinical assessment of TD. The framework is
based on known cognitive dissociations in the realm of topographical cogni-
tion and draws heavily on theories proposed by Riddoch and Humphreys
(1989), Farah (1984), and Kosslyn (1980).

TOPOGRAPHICAL DISORIENTATION AND COGNITIVE

DISSOCIATIONS
Comprehensive historical reviews of TD in terms of case descriptions, assess-
ment issues and neuroanatomical correlates can be found elsewhere (Barrash,
1998; Farrell, 1996). Here, we focus on providing a summary of published
evidence for a number of cognitive dissociations within TD (also see
Table 1 which summarises relevant reported cases).

Topographical disorientation as a specific disorder

TD can occur in patients with otherwise intact visual perception and intact
visual recognition skills. In the domains of both recognition and memory,
TD cases have been reported with impaired processing of topographical infor-
mation but intact recognition and/or memory for faces and objects (e.g., della
Rocchetta et al., 1996; Suzuki et al., 1998). TD can also occur in the absence
of general spatial impairment (as assessed by traditional neuropsychological
tests of spatial skills), including both spatial perception and spatial memory
impairment. For example, case MS (della Rocchetta et al., 1996) acquired
TD suddenly as a result of small vessel ischaemic disease. General visual
perceptual and visual spatial abilities were intact. Assessment included
tests of face perception, object perception (including from unusual views),
and subtests from the VOSP (Visual Object and Space Perception Battery,
Warrington & James, 1991). New learning and recognition memory for
faces and words fell within normal limits, as did new learning of non-
topographical spatial information. In contrast, naming of famous landmarks
was impaired, and new learning and recognition memory for city buildings
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 37

TABLE 1
Topographical disorientation and cognitive dissociations: A brief overview

Dissociation Example Reference

Topographical disorientation as a specific disorder

Topographical disorientation can occur in the absence of:
1. General visual perceptual and recognition
impairments (including object agnosia and
prosopagnosia)
2. General spatial perceptual impairments
3. General visual and spatial memory impairments
(including new learning and memory for objects
and faces).
Hublet & Demeurisse (1992), Luzzatti et al.
(1998), Stark, Coslett, & Saffran (1996)
della Rocchetta et al. (1996), Hublet &
Demeurisse (1992), Suzuki et al. (1998),
Whiteley & Warrington (1978)
Maguire et al. (1996), Suzuki et al. (1998),
della Rocchetta et al. (1996)

Dissociations within topographical disorientation: Recognition and memory

Topographical disorientation can be characterised by:
1. Impaired recognition of topographical landmarks
but intact memory for the spatial layout of the
environment
2. Intact recognition of topographical landmarks but
impaired memory for the spatial layout of the
environment
3. Impairments in anterograde memory (new
learning) of topographical information but intact
retrograde memory
4. Intact drawing of plans/maps of premorbidly
known places but not newly learned places
5. Impaired recognition and memory for
topographical scenes but intact recognition and
memory of landmark buildings
Haecan et al. (1980), Landis et al. (1986),
McCarthy et al. (1996), Whiteley &
Warrington (1978)
Bottini et al. (1990), Luzzatti et al. (1998),
Luzzi et al. (2000), Mendez & Cherrier
(2003)
Davis & Coltheart (1999), Habib & Sirigu
(1987), Hublet & Demeurisse (1992),
Katayama et al. (1999)
Epstein et al. (2001)
Mendez & Cherrier (2003)

Dissociations within topographical disorientation: Imagery

1. A general dissociation has been proposed between Farah (1988), Farah et al. (1988), Levine
general imagery of visual and spatial information et al. (1985), Luzzi et al. (2000)
2. Intact imagery of landmarks but inability to Cogan (1979), Levine et al. (1985), Luzzatti
visualise route finding et al. (1998)
3. Intact topographical spatial imagery but impaired Farah et al. (1988)
object visual imagery and/or imagery for
landmarks

Dissociations within topographical disorientation: Map reading/drawing skills

1. Impaired real-life route-finding but intact Epstein et al. (2001), Landis et al. (1986),
drawing and following of maps Mendez & Cherrier (2003), Whiteley &
Warrington (1978)
2. Intact real-life topographical orientation but Benson (1989)
difficulty with “visual geographic functions”
including interpreting and following maps or
plans
38 BRUNSDON, NICKELS, COLTHEART

and countryside scenes was at chance level. In addition, MS was unable to

describe highly familiar routes (e.g., from her home to the local supermarket).
In summary, a number of cases (see Table 1) provide evidence that TD can
occur as a relatively specific disorder. That is, processing impairments for
topographical information can occur independently of other classes of
visual stimuli, such as objects, faces and words, and independently of
general perceptual or spatial cognitive impairments. Such impairments can
impact on topographical orientation, thus are important to consider in assess-
ment, but are not necessary to cause TD.

Recognition of landmarks and memory for routes

Within topographical cognition itself, there is evidence for a double dis-
sociation between recognition and memory. That is, recognition of topogra-
phical information (such as landmarks and buildings) can be impaired
independently of memory for topographical spatial information. For
example, cases with TD have been described who report that familiar
environments no longer look familiar, but who can demonstrate intact
memory for the spatial layout of environments by drawing maps or describing
routes. Landis et al. (1986) report a 51-year-old man who acquired persistent
TD characterised by marked difficulties with recognition of familiar environ-
ments following an embolic stroke. His own house remained unfamiliar to
him and he relied on features such as the presence of two palm trees in
order to locate it. In contrast, he was able to draw and follow maps, and
managed to navigate his local neighbourhood competently by memorising
street names. The opposite profile has also been reported, that is cases of
TD who recognise familiar landmarks relatively well but cannot navigate
between them successfully (refer to Table 1 for references).
Within the domain of recognition, there is evidence for a dissociation
between recognition of topographical scenes (e.g., street scapes or junctures)
and topographical landmarks (e.g., buildings, monuments). Mendez and
Cherrier (2003) report case GN who, following a stroke (presumed migrainous
in aetiology), had difficulty navigating familiar environments. He was able to
draw maps and give verbal directions of familiar routes, but reported that
when he was navigating familiar routes in everyday life the routes looked
unfamiliar. Careful testing revealed that GN was able to recognise familiar
landmarks (and even describe what direction to take from these landmarks),
but was unable to recognise critical scenes along each route (where scenes
were key sections or junctures within the routes, devoid of major salient
landmarks).
Within topographical memory, case studies suggest separable mechanisms
for encoding new information when compared to recall of old information.
Many patients experience TD in both familiar and unfamiliar environments
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 39

(e.g., Bottini, Cappa, Geminiani, & Sterzi, 1990; della Rocchetta et al., 1996;
De Renzi et al., 1977; Habib & Sirigu, 1987; Hecaen, Tzoerzis, & Rondot,
1980; Landis et al., 1986; Suzuki et al., 1998). However, TD in unfamiliar
environments (i.e., the inability to learn new topographical information)
can occur in patients who have no reported difficulties with navigating
familiar environments. Habib and Sirigu (1987) report a case of TD with
striking disorientation in new surroundings (such as the hospital ward, new
places and new neighbourhoods). However, no difficulties were reported in
his home environment, local neighbourhood or even larger familiar cities
(e.g., TD was able to navigate familiar routes in Paris by car).
Moreover, cases have been reported for whom recognition of landmarks is
relatively intact and route descriptions are intact (demonstrating intact recog-
nition and memory skills for topographical information), but they have TD in
real-life settings because landmarks fail to convey directional information
(e.g., Suzuki et al., 1998). For example, case TY (Suzuki et al., 1998) was
able to identify single objects, sets of objects and her house accurately
from normal and different viewpoints. She was also able to draw a complete
plan of her house and local environment and describe routes accurately.
However, when asked to point to the standpoint from which the photo was
taken (on a plan of the stimulus and photographic angles), she was able to
do so for non-topographic objects, but not for photos of her own house.
So, in sum, within recognition and memory impairments there is evidence
to suggest relatively distinct processing of topographical spatial information
and topographical visual landmark information with probable further dis-
sociations within each domain (e.g., according to type of topographical
stimuli (e.g., scenes/buildings) or type of processing (e.g., encoding/
retrieval).

Imagery of topographical information

Visual imagery is a particularly important aspect of cognition in topogra-
phical orientation. Patients with TD have been described who report
general difficulty with revisualisation or internal representation of spatial
environments. Moreover, a dissociation has been proposed between
imagery of visual and spatial topographical information (Farah, 1988;
Farah, Levine, & Calvanio, 1988; Levine, Warach, & Farah, 1985; Luzzatti
et al., 1998; Luzzi, Pucci, Di Bella, & Piccirilli, 2000). For example, case
EP (Luzzatti et al., 1998) was able to describe visual characteristics of
famous monuments but was unable to describe spatial relations between
familiar streets and squares. Similarly, Cogan’s (1979) patient reports “I
can see clearly in front of me the Copley Square Library and front of the
Copley Plaza Hotel, but I cannot picture in my mind how I would walk or
drive there”, “I can picture the Harvard Stadium . . . but my approach to [it]
40 BRUNSDON, NICKELS, COLTHEART

is blotted out in my memory”, “I cannot for the life of me mentally visualize

what is beyond my periphery of sight” [p. 362]. Interestingly, the opposite
pattern has also been reported where topographical spatial imagery appears
relatively intact, in the context of impaired object visual imagery (Farah,
et al., 1988). Case RM (Farah et al., 1988) had difficulty describing visual
characteristics of famous buildings, but was able give an adequate description
of the route from his home town to Paris.

Map reading skills

Finally, the dissociation between topographical orientation in real life and
general topographic (ability to draw, use and interpret maps) skills has
been frequently highlighted. Patients have been reported who cannot navigate
environments in daily life but can draw and/or follow maps successfully
(Epstein et al., 2001; Landis et al., 1986; Mendez & Cherrier, 2003; Suzuki
et al., 1998; Whiteley & Warrington, 1978). Benson (1989) also reminds us
of the opposite pattern which he calls “topographognosia” referring to
patients with normal topographical orientation but difficulty with “visual
geographic functions” including interpreting maps and house plans. These
patients often perform normally in real situations but cannot place themselves
on or draw a map or plan.

TD and cognitive dissociations: A summary

This review of the literature provides considerable evidence that normal topo-
graphical orientation requires the integration of a number of relatively inde-
pendent cognitive functions. Firstly, topographical orientation can be affected
by general visuospatial perceptual and memory impairments (as assessed
using traditional neuropsychological measures), but these impairments are
not necessary to cause TD. It appears that processing impairments for topo-
graphical information can occur independently of other classes of visual
stimuli, such as objects, faces and words. Secondly, within topographical cog-
nition itself, there is evidence for a double dissociation between recognition
and memory. Within topographical memory, case studies suggest separable
mechanisms for encoding new information when compared to recall of old
information. Furthermore, within recognition and memory impairments
there is evidence to suggest relatively distinct processing of topographical
spatial information and topographical visual landmark information, and
even a recent dissociation between impaired processing of topographical
scenes and intact processing of landmarks. Similar dissociations between
visual and spatial processing have been reported in topographical imagery.
Finally, the dissociation between topographical orientation in real life and
general topographic (ability to draw, use and interpret maps) skills has
been frequently highlighted.
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 41

TOPOGRAPHICAL DISORIENTATION AND THEORETICAL

PROPOSALS
A number of authors have proposed general classifications or taxonomies of
TD in an effort to organise contrasting cases of TD into general syndromes.
Two examples will be described to demonstrate this approach (Aguirre &
D’Esposito, 1999; DeRenzi, 1985).
DeRenzi’s (1985) frequently cited framework focuses on processing of
spatial information and describes three levels of spatial disorientation:
disorders of space exploration (which are conceptualised as akin to
Balint-Holmes’ Syndrome)1; disorders of space perception and cognition
(impairments in perception of stimulus spatial characteristics and in
performing mental transformations); and disorders of space memory (impair-
ments in memory for location and relative location of objects). This final level
according to DeRenzi (1985) would cause TD, and more specifically
“topographical amnesia”, which he distinguishes from the inability to
recognise landmarks.
Aguirre and D’Esposito (1999) propose a four-part taxonomy of TD that
characterises four different subtypes of TD (“egocentric disorientation”,
“heading disorientation”, “landmark agnosia”, and “anterograde disorienta-
tion”) outlining both patterns of impairment and underlying neuropathology.
For example, “egocentric disorientation”, is proposed to arise from lesions of
posterior parietal cortex. It is characterised by a severe general visuo-spatial
disorientation that is not specific to topographical skills, but also affects
general spatial perception, memory and imagery. Patients with egocentric dis-
orientation are disoriented in both familiar and unfamiliar environments, and
exhibit impairments in map drawing and route description, but recognition of
objects is relatively intact. In contrast, “landmark agnosia” is characterised
by an inability to recognise landmarks for the purpose of orientation, and is pro-
posed to arise from lesions of medial aspect of occipital lobe involving the fusi-
form and lingual gyri. Disorientation is evident in both familiar and novel
environments, but spatial skills, spatial representation, map drawing and
route description are relatively intact.
Cognitive information-processing frameworks have been proposed for
cognitive processes that are considered important in topographical orientation
such as visual attention (e.g., Humphreys & Riddoch, 1992; Posner &
Peterson, 1990) visual object recognition (e.g., Ellis & Young, 1988;
Farah, 1990; Humphreys & Riddoch, 1987, 1994; Riddoch & Humphreys,
1993), working memory (e.g., Baddeley, 1981) and visual/spatial memory

1
Balint-Holmes’ syndrome is characterised by apraxia of gaze, optic ataxia, disorders of
visual attention and defective estimation of distance (De Renzi, 1985) and in general presents
as an impairment in the scanning of space and inability to attend appropriately to a target(s).
42 BRUNSDON, NICKELS, COLTHEART

and imagery (e.g., Farah, 1984; Kosslyn, 1980). But to our knowledge the
framework proposed by Riddoch and Humphreys (1989) represents the
only cognitive neuropsychological framework dedicated to explaining
topographical cognition as a whole. The following discussion will focus on
theories of imagery proposed by Farah (1984) and Kosslyn (1980) and the
theoretical proposal by Riddoch and Humphreys (1989) as these form the
basis of the integrated framework used in this paper.

Visual imagery
There is a consensus of opinion in the literature that visual imagery is import-
ant in normal topographical orientation (Farah, 1989). Visual imagery refers
to the “short term memory representations that lead to the experience of
‘seeing with the mind’s eye’” (Kosslyn et al., 1993). It is presumed that
individuals employ mental visual images in many aspects of topographical
cognition (Davis & Coltheart, 1999; Farah, 1989; Riddoch & Humphreys,
1989) such as when drawing maps (or floor plans) of familiar environments,
describing well-known routes, describing familiar landmarks and presumably
when encoding and learning new routes. Recognition of landmarks, scenes
and maps also requires matching the environmental stimuli with stored
visual images. Individuals also manipulate and change mental images when
following topographical routes (i.e., when they are required to constantly
update the image in terms of their current position and perspective).
Kosslyn’s (1980) framework of visual object imagery includes two main
structures, a long-term visual memory structure (that stores information
about the appearances of objects) and a visual memory buffer (that acts as
a temporary visual store during processing). Kosslyn (1980) also proposes
three main processes that occur during normal visual object imagery. The
“generate” process retrieves the visual image from long-term memory and
represents its parts in the visual memory buffer. The “inspect” process con-
verts the pattern of activation in the visual buffer into an organised coherent
percept of an object, identifying parts and relations within the image ready for
further processing. The “transform” process allows for manipulations of the
image including transformations and rotations (Kosslyn, 1980; 1987).
Kosslyn (1987) proposes a complex framework for mental imagery involving
12 subsystems (including those just outlined) hypothesised to be used in both
visual imaging and visual perception. A detailed review of all 12 subsystems
is not necessary for the purposes of this current paper.
Farah’s (1984) information-processing model of imagery expands the
model proposed by Kosslyn (1980) to allow for the development of theoreti-
cally driven assessment, by explicitly stating input and output processes.
Farah’s (1984) model adds three new components: “describe” (for question
and answer tasks that require inspection of the image in the visual buffer);
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 43

“copy” (for drawings or constructions that are created following an inspection

of visual buffer); and “detect” (which refers to tasks in which an image is
simply detected but not inspected or processed). Farah (1984) also adds
two sensory processes: a visual encoding process (which encodes stimuli
into the buffer) and a recognition process (which matches the contents of
the visual buffer with long-term memories). Farah (1984) makes the assump-
tion, based on research evidence (Farah, 1988; Kosslyn, 1987), that long-term
visual images used in image generation are the same as those used in recog-
nition. She provides a clear framework for assessing visual imagery in terms
of a task analysis and provides good evidence from a review of published
cases for object imagery deficits arising from different levels of impairment
(e.g., generation processes deficit, a long-term visual memory deficit, or an
inspection process deficit).

Topographical cognition
Riddoch and Humphreys (1989) provide the most comprehensive framework
of topographical cognition and an excellent foundation for a cognitive neu-
ropsychological model of topographical orientation. Their conceptualisation
of topographical cognition begins with early perception of visual stimuli
across the visual field in both 2D and 3D space, including perception of
depth, perception of spatial location of single objects and also the spatial
relationship between multiple objects. They consider these visual and
spatial perceptual skills as important for recognition of topographical
stimuli. They acknowledge the need for more research investigating the
effect of early perceptual impairments on topographical orientation, but
propose that some more severe forms of early perceptual impairment
certainly could impact on topographical orientation and need to be considered
and assessed as possible factors affecting performance (Riddoch &
Humphreys, 1989). They also acknowledge the need for a spatial working
memory system to provide a flexible and temporary store for one’s current
position on a route (which is constantly changing) to allow for planning of
future movements. They propose that this ability to maintain one’s position
on a route while also updating and planning future movements is a joint
function of the spatial sketch pad and central executive systems. Attentional
processes are also considered important for “initiation and co-ordination of
actions in response to the appropriate environmental cues”. Finally they
discuss the need for access to long-term stored memories of familiar
landmarks and routes and stress the importance of the distinction between
loss of actual knowledge and difficulty with accessing or retrieving it.
In summary, Riddoch and Humphreys (1989) break down TD into:
impairments in viewpoint-dependent representations (early perception of
visual characteristics, depth perception and perception of distances between
44 BRUNSDON, NICKELS, COLTHEART

objects); impairments in perceptual integration (integration of early percep-

tion into a coherent whole); problems in representing and using spatial infor-
mation in working memory; and disorders of long-term topographical
memory. A framework of at least this scope seems necessary to cover all
aspects of cognition thought to be involved in topographical cognition, that
is, from visual perception of single objects to representations of world geogra-
phy (Byrne, 1982).

TOPOGRAPHICAL ORIENTATION: TOWARDS AN INTEGRATED

COGNITIVE FRAMEWORK
The integrated cognitive framework shown in Figure 1 represents a broad
sketch of cognitive processes involved in topographical cognition (based
on an integration of the cognitive frameworks just outlined). The framework
was designed as a guide for comprehensive theoretically based assessment of
cases with TD.
As shown in Figure 1, it is proposed that there are three main levels of pro-
cessing in normal topographical orientation. The first level of processing
involves the perception of single objects in both two and three dimensions.
This includes perception of visual object characteristics such as length,
colour, size, form, movement, orientation and location (Ellis & Young,
1988; Farah, 1990; Humphreys & Riddoch, 1987; 1994) as well as the percep-
tion of depth and figure ground which are important for formation of a three-
dimensional percept (as discussed in Riddoch & Humphreys, 1989). The
second main level of processing involves the integration of early perceptual
processes into the formation of a representation of multiple objects across
the visual field. It is proposed that an essential component of this involves
the perception and coding of the spatial relations between objects. In addition,
as with single object processing, a topographical landmark, scene or spatial
map could be represented both in a viewpoint dependent and viewpoint inde-
pendent manner, although it is proposed here that the latter would be required
for normal topographical orientation. The final level of processing represents
the “core” of topographical cognition where encoding, processing, manipu-
lation and formation of long-term representations of topographical infor-
mation occur (for both routes and landmarks). This level of topographical
processing includes interactions between the visuospatial working memory
system and the attention/executive system for the complex cognitive task
of maintaining, updating and planning one’s current and future positions on
a topographical route. The other important interaction represented at this
level of topographical processing occurs between the visuospatial working
memory and long-term memory systems allowing for processing and encod-
ing of new topographical information, recognition of known topographical
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 45

Figure 1. Integrated model of topographical processing.

information (through a comparison of short-term and long-term memory rep-

resentations) and also the retrieval of information from long-term memory for
completion of tasks that require map drawing or route description. Semantic
representation of topographical knowledge is also represented in this frame-
work based on the assumption that topographical orientation requires some
knowledge of the meaning of landmarks and the surrounding environment.
46 BRUNSDON, NICKELS, COLTHEART

McCarthy, Evans, and Hodges (1996) in their report of case SE, who pre-
sented with impaired topographical recognition, provide evidence for a
core underlying central semantic deficit.2

TOPOGRAPHICAL DISORIENTATION AND ASSESSMENT

The literature has been plagued by a lack of theoretically driven assessment
which has lead to the use of a variety of different assessment protocols for
investigation of TD. Assessment methods have commonly consisted of
general observation and/or recording of client reports of the topographical
difficulties supplemented by neuropsychological “table-top” tests of general
spatial perception, recognition, and memory. Some studies have employed
additional specific tests involving photos of landmarks or familiar regions,
small-scale maps or plans (Bottini et al., 1990; della Rocchetta et al., 1996;
Hublet & Demeurisse, 1992; Luzzatti et al., 1998; Semmes et al., 1963;
Suzuki et al., 1998), videos (Maguire, Burke, Phillips, & Staunton, 1996),
or even virtual reality (in fMRI studies with normal subjects, Aguirre &
D’Esposito, 1997; Aguirre, Detre, Alsop, & D’Esposito, 1996) for assessment
of route finding and landmark recognition. However, assessment of topogra-
phical orientation in large-scale real-life environments is rarely conducted
(Barrash, 1994; Mendez & Cherrier, 2003) even though most authors now
agree that it should be an essential component of evaluating TD (Farrell,
1996; Georgemiller & Hassan, 1986; Maguire et al., 1996; Mendez &
Cherrier, 2003). In summary, historically, assessment of topographical
orientation has for the most part been inconsistent, incomplete, has lacked
sensitivity to the specific topographical deficits, and has failed to assess
real-life topographical functioning in large-scale spaces in more than a
cursory way.

THE INTEGRATED FRAMEWORK AND ASSESSMENT

As a guide for assessment, the integrated framework outlines areas of
cognition thought to be involved in normal topographical orientation. The
framework suggests that assessment of TD should be broad, encompassing
2
Case SE, following an episode of viral encephalitis, complained of great difficulty finding
his way around previously familiar environments (such as his home town) which he now
described as appearing unfamiliar. He was unable to recognise familiar buildings (including
his own house), but produced a remarkably detailed and accurate map drawing of his home
town. In addition, however, case SE had difficulty providing semantic information about
famous buildings when their names were presented verbally. Thus, SE’s difficulties may
have resulted from an underlying semantic deficit rather than from a pure recognition deficit.
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 47

perception, spatial processing, memory and imagery as well as specific topo-

graphical skills such route finding and map following.

Level 1: Perception of single objects

Assessment of early visual perception of objects is indicated by the first level
of the integrated framework. Assessment of perception should include
detailed analyses of early visual analysis and figure ground formation, an
area of assessment already well established in cognitive neuropsychology
(e.g., subtests 2– 6 from the Birmingham Object Recognition Battery,
BORB; (Riddoch & Humphreys, 1993).

Level 2: Perception of multiple objects in the visual field

The next stage of assessment involves investigation of perception of multiple
objects in the visual field. In order to achieve an adequate percept of the visual
field one must be able to accurately perceive single and multiple objects from
various viewpoints, and also the spatial relations between them. Thus, assess-
ment of this level of processing should include tests of single object percep-
tion from unusual views (e.g., subtests 7 and 8 from the BORB), and
perception of topographical landmarks and scenes from different viewpoints
(e.g., using photographs). In addition, perception of spatial relations between
objects should be investigated such as perception and/or discrimination of
relative spatial location and spatial orientation (e.g., subtests 6 –7 from the
Visual Object and Space Perception Battery, VOSP; Warrington & James,
1991). In addition, visual perceptual tasks involving multiple stimuli (even
a photo of a visual scene) with task demands such as indicating which stimu-
lus is higher than another or which is closer to a target, or which of two stimuli
is further away from the viewer.

Level 3: The core of topographical cognition

The final level of processing represents the biggest challenge in terms of
assessment. Assessment must incorporate the range of cognitive processes
required for recognition, encoding, and retrieval of visual and spatial infor-
mation, as well as specific topographical material.

Recognition, new learning and memory. Assessment must encompass

visual and spatial short-term memory, and encoding and long-term retrieval
of visual and spatial information (using standard neuropsychological
measures, e.g., Wechsler Memory Scales, Wechsler, 1997; Children’s
Memory Scale, Cohen, 1997; Test of Memory and Learning, Reynolds &
Bigler, 1994; Benton Visual Retention Test, Benton, 1974). Recognition
and memory for specific topographical material should also be assessed.
48 BRUNSDON, NICKELS, COLTHEART

For example, two core elements of topographical assessment at this level

should be: new learning of routes and landmarks (using paper and pencil
tasks, photographs and “real-life” route-finding tasks) and retrieval of well-
learned topographical information (e.g., verbally describing frequently used
routes and visual characteristics of familiar landmarks, and/or drawing
plans or maps of familiar environments).

Imagery. Entwined in assessment of topographic memory is assessment

of imagery, as short-term and long-term visuo-spatial memory tasks require
the use of imagery. To our knowledge, the finer distinctions between
aspects of long-term memory, short-term memory, and imagery processes
such as generation, encoding and inspection of images (as discussed by
Farah, 1984), have not yet been carefully investigated in the realm of TD.
Nevertheless Farah (1984) does provide an excellent framework for assess-
ment of visual imagery deficits, which could be applied to topographical
stimuli. For example, an individual with TD who fails to describe (or
draw) the visual appearance of famous landmarks from memory, but is
able to describe (or copy) and recognise visually presented pictures of land-
marks, is likely to have a deficit in image generation.3 An individual who can
describe (and/or copy) visually presented landmarks or routes but cannot
recognise them or describe them from memory, is likely to have a deficit in
long-term visual memory, particularly if both the recognition and imagery
deficit concur in term of category specificity (as this allows more certainty
in presuming a deficit in image storage rather than generation) (readers are
referred to Farah, 1984, for further examples).

Executive and semantic processing. Given the proposed impact of atten-

tion, executive and semantic impairments on topographical orientation,
detailed neuropsychological assessment of these other related cognitive
processes is also recommended.

Assessment of route finding in large-scale space. The importance of

assessment of TD in the real-life environment must be stressed. Assessment
of real-life route finding should not involve a unitary measure (e.g., whether
the destination is successfully reached or not), but should be assessed in a
multidimensional way with a range of outcome measures (e.g., percentage
of routes failed, percentage of incorrect steps or turns, number of hesitations
and time taken) providing formal analyses of both quantitative and qualitative
aspects of route finding. We would argue that this form of assessment in
3
Assuming that long-term visual memories used in image generation are the same memories
that are used in visual recognition (Farah, 1984).
 TOPOGRAPHICAL DISORIENTATION: AN INTEGRATED FRAMEWORK 49

large-scale space is essential, not just for treatment studies but also for
detailed case investigations.

Map reading
Finally, assessment of map-following skills can provide useful insights into
the more complex high level demands of interactions between working
memory, executive, attention and spatial skills in combination and in practice.
Information regarding map-following skills is also useful for treatment
planning.

FINAL COMMENTS
The integrated framework outlined above, at this stage, represents a broad
sketch of cognitive processes thought to be involved in topographical cogni-
tion. The aim of the current paper was to develop a preliminary framework
that could provide a rationale for assessment planning and interpretation. It
is hoped that the current framework will stimulate further research in this
area and particularly more cases studies of topographical disorientation that
include a comprehensive theoretically based assessment (including assess-
ment of real-life route finding). Cognitive neuropsychological studies that
carefully evaluate all aspects of topographical cognition as well as real-life
route-finding skills will be invaluable for future development and refinement
of this framework, hopefully leading to a more widely accepted cognitive
neuropsychological model of normal topographical cognition in the future.

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Manuscript received May 2005

Revised manuscript received November 2005