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Larner AJ, Leff AP, Nachev PC. Phantasia, aphantasia, and hyperphantasia: Empirical data and conceptual considerations. Neurosci Biobehav Rev 2024; 164:105819. [PMID: 39032843 DOI: 10.1016/j.neubiorev.2024.105819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/08/2024] [Accepted: 07/17/2024] [Indexed: 07/23/2024]
Abstract
Within the past decade, the term "phantasia" has been increasingly used to describe the human capacity, faculty, or power of visual mental imagery, with extremes of imagery vividness characterised as "aphantasia" and "hyperphantasia". A substantial volume of empirical research addressing these constructs has now been published, including attempts to find inductive correlates of behaviourally defined aphantasia, for example using research questionnaires and functional magnetic resonance imaging. Mental imagery has long been noted as a source of conceptual confusions but no specific conceptual analysis of the new formulation of phantasia, aphantasia, and hyperphantasia has been undertaken hitherto. We offer some conceptual considerations on phantasia, noting the ongoing confusion of perceptual with mental images, and the ubiquitous use of unvalidated subjective assessment instruments such as the Vividness of Visual Imagery Questionnaire (VVIQ) in diagnosis and assessment, development of which was predicated on these conceptual confusions. We offer some suggestions for a conceptual framework for future empirical studies in this field, circumventing these conceptual confusions.
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Affiliation(s)
- A J Larner
- Department of Brain Repair & Rehabilitation, Institute of Neurology, University College London, London, United Kingdom.
| | - A P Leff
- Department of Brain Repair & Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
| | - P C Nachev
- Department of Brain Repair & Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
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Young MJ, Kazazian K, Fischer D, Lissak IA, Bodien YG, Edlow BL. Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation. Neurocrit Care 2024; 40:865-878. [PMID: 38243150 PMCID: PMC11147696 DOI: 10.1007/s12028-023-01899-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 01/21/2024]
Abstract
The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA.
| | - Karnig Kazazian
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Western Institute of Neuroscience, Western University, London, ON, Canada
| | - David Fischer
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - India A Lissak
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 101 Merrimac Street, Suite 310, Boston, MA, 02114, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
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Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant, and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically-responsible care in this domain are especially timely given recent surges in critically ill patients with unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness, and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and up until the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery, and ethical issues that arise within the context of caring for persons with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI 02906, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, Department of Veterans Affairs Medical Center, Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA
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Huang TL, Lin CC, Chen HL, Lu CH. Catatonia Rating Scales in Patients with Persistent Vegetative State. TAIWANESE JOURNAL OF PSYCHIATRY 2020. [DOI: 10.4103/tpsy.tpsy_9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Napier S. The Minimally Conscious State, the Disability Bias, and the Moral Authority of Advance Directives. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 65:101333. [PMID: 29661479 DOI: 10.1016/j.ijlp.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Stephen Napier
- SAC 108, Philosophy Department, 800 Lancaster Ave., Villanova, PA 19085, USA.
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Wade DT. How often is the diagnosis of the permanent vegetative state incorrect? A review of the evidence. Eur J Neurol 2018; 25:619-625. [DOI: 10.1111/ene.13572] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 01/08/2018] [Indexed: 12/11/2022]
Affiliation(s)
- D. T. Wade
- OxINMAHR, and Movement Science Group; Faculty of Health and Life Sciences; Oxford Brookes University; Oxford UK
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Ragazzoni A, Cincotta M, Giovannelli F, Cruse D, Young GB, Miniussi C, Rossi S. Clinical neurophysiology of prolonged disorders of consciousness: From diagnostic stimulation to therapeutic neuromodulation. Clin Neurophysiol 2017; 128:1629-1646. [DOI: 10.1016/j.clinph.2017.06.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/17/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
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Wade D. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness. JOURNAL OF MEDICAL ETHICS 2017; 43:457-458. [PMID: 27501786 DOI: 10.1136/medethics-2015-103140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 05/11/2023]
Abstract
In 1993, the UK High Court decided that Tony Bland was unaware of himself and his environment, had no interest in medical treatment and allowed withdrawal of treatment. Subsequently, the court has reviewed all cases of stopping feeding and hydration in people with a prolonged disorder of consciousness. Their focus has been on determining whether the person is in the permanent vegetative state, because this avoids considering what is in a person's Best Interests. Consequently, much resource is spent distinguishing the vegetative state from the minimally conscious state and often clinical decisions are delayed or not made because of the requirement to go to court. In this paper, I argue that the neurophysiological basis of consciousness is unknown, and one cannot test whether the necessary structures are functioning. Unconscious people have responsiveness which varies; they may even have brief behaviours suggestive of awareness. No single clinical sign or investigation nor assessment battery can prove the presence (or absence) of consciousness or its permanence. The diagnosis of consciousness is clinical. Furthermore, awareness varies across a spectrum. There is no separate vegetative state. People simply have very limited or absent awareness. Even if there were such a state, it cannot be identified. The ethical and legal issues associated with decisions on treatment of unconscious people are no different from similar decisions in other patients. All decisions should be taken within the Best Interests framework and process. There should be no requirement to take any particular decision to court in this patient group.
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Cortical connectivity modulation induced by cerebellar oscillatory transcranial direct current stimulation in patients with chronic disorders of consciousness: A marker of covert cognition? Clin Neurophysiol 2016; 127:1845-54. [PMID: 26754875 DOI: 10.1016/j.clinph.2015.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 12/09/2015] [Accepted: 12/15/2015] [Indexed: 11/20/2022]
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Abstract
In this paper, I examine Jeff McMahan's arguments for his claim that we are not human organisms, and the arguments of Derek Parfit to the same effect in a recent paper. McMahan uses these arguments to derive conclusions concerning the moral status of embryos and permanent vegetative state (PVS) patients. My claim will be that neither thinker has successfully shown that we are not human beings, and therefore these arguments do not establish the ethical conclusions that McMahan has sought to draw from the arguments in respect of the moral status of embryos and PVS patients.
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Affiliation(s)
- Andrew McGee
- Queensland University of Technology, Brisbane, Queensland, Australia
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Schnakers C, Giacino JT, Løvstad M, Habbal D, Boly M, Di H, Majerus S, Laureys S. Preserved Covert Cognition in Noncommunicative Patients With Severe Brain Injury? Neurorehabil Neural Repair 2014; 29:308-17. [PMID: 25160566 DOI: 10.1177/1545968314547767] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background. Despite recent evidence suggesting that some severely brain-injured patients retain some capacity for top-down processing (covert cognition), the degree of sparing is unknown. Objective. Top-down attentional processing was assessed in patients in minimally conscious (MCS) and vegetative states (VS) using an active event-related potential (ERP) paradigm. Methods. A total of 26 patients were included (38 ± 12 years old, 9 traumatic, 21 patients >1 year postonset): 8 MCS+, 8 MCS−, and 10 VS patients. There were 14 healthy controls (30 ± 8 years old). The ERP paradigm included (1) a passive condition and (2) an active condition, wherein the participant was instructed to voluntarily focus attention on his/her own name. In each condition, the participant’s own name was presented 100 times (ie, 4 blocks of 25 stimuli). Results. In 5 MCS+ patients as well as in 3 MCS− patients and 1 VS patient, an enhanced P3 amplitude was observed in the active versus passive condition. Relative to controls, patients showed a response that was (1) widely distributed over frontoparietal areas and (2) not present in all blocks (3 of 4). In patients with covert cognition, the amplitude of the response was lower in frontocentral electrodes compared with controls but did not differ from that in the MCS+ group. Conclusion. The results indicate that volitional top-down attention is impaired in patients with covert cognition. Further investigation is crucially needed to better understand top-down cognitive functioning in this population because this may help refine brain-computer interface–based communication strategies.
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Affiliation(s)
- Caroline Schnakers
- University Hospital of Liège, Liège, Belgium
- University of Liège, Liège, Belgium
| | - Joseph T. Giacino
- Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, MA, USA
- JFK Johnson Rehabilitation Institute, Edison, NJ, USA
| | - Marianne Løvstad
- Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
- University of Oslo, Oslo, Norway
| | - Dina Habbal
- University Hospital of Liège, Liège, Belgium
- University of Liège, Liège, Belgium
| | - Melanie Boly
- University Hospital of Liège, Liège, Belgium
- University of Liège, Liège, Belgium
| | - Haibo Di
- Hangzhou Normal University, Hangzhou, China
| | | | - Steven Laureys
- University Hospital of Liège, Liège, Belgium
- University of Liège, Liège, Belgium
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Pandit JJ. Isolated forearm - or isolated brain? Interpreting responses during anaesthesia - or 'dysanaesthesia'. Anaesthesia 2013; 68:995-1000. [PMID: 24047288 DOI: 10.1111/anae.12361] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
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"Complete motor locked-in" and consequences for the concept of minimally conscious state. J Head Trauma Rehabil 2013; 28:141-3. [PMID: 22333679 DOI: 10.1097/htr.0b013e31823c9eaf] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The demonstration by Monti et al. (2010) of willful modulation of brain activity in persistent vegetative state implies the exceptional condition of a "complete motor locked-in syndrome." As a consequence, the contradictory character of the diagnosis minimally conscious state should be recognized because behaviorally observed minimal cognitive responsiveness does not exclude a higher level of well-differentiated self-consciousness. Introduction of the descriptive entities "complete motor locked-in syndrome" and "minimal cognitive responsiveness" is therefore advocated in the service of diagnostic precision.
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Lee YC, Lei CY, Shih YS, Zhang WC, Wang HM, Tseng CL, Hou MC, Chiang HY, Huang SC. HRV response of vegetative state patient with music therapy. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2011:1701-4. [PMID: 22254653 DOI: 10.1109/iembs.2011.6090488] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This case study centered on the effects of Music Therapy (MT) on vegetative state (VS) patients for a continuous 41-day experiment with electrocardiogram (ECG) recorded. Mahler's Second Symphony was used for this MT. There are various elements in Mahler's second symphony, with string, wind, drum, and even voice; providing the subject a strong and dynamic stimulation. There are some significant changes after 14-day stimulation: both standard deviation of all normal RR intervals (SDNN) and root mean square successive differences (RMSSD) in heart rate variability of the subject increased, indicating the activity of the cardiovascular system was enhanced. Although there's only one subject in this experiment, the results are still encouraging.
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Affiliation(s)
- Yaw-Chern Lee
- sense/tcm SOC Lab, Department of Electrical Engineering, National Chiao Tung University, Hsinchu, Taiwan
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Abstract
PURPOSE OF REVIEW Recent neuroimaging studies have provided novel insights on residual brain function in patients with disorders of consciousness, but also raised a number of ethical issues concerning the clinical management of these patients. RECENT FINDINGS Clinical studies have rated the Coma Recovery Scale as the most appropriate scale to accurately differentiate patients in a vegetative state from patients in a minimally conscious state. At the population level, a number of neuroimaging studies have provided evidence for more preserved brain activity patterns and cerebral tissue integrity in minimally conscious as compared to vegetative-state patients. However, the use of neuroimaging techniques to diagnose consciousness at the single-patient level remains challenging. In particular, it has been shown that whereas command-following functional MRI paradigms may sometimes detect residual awareness in patients that are behaviorally unresponsive, they can also produce negative results in patients that are communicative at the bedside. SUMMARY There is an urgent need of validation of functional MRI active paradigms on larger patient populations before they can be used in clinical routine. Further research on neural correlates of consciousness should hopefully allow using passive paradigms to assess the patients' conscious state without requiring their active collaboration.
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Action and the fallacy of the ‘internal’: Comment on Passingham et al. Trends Cogn Sci 2010; 14:192-3; author reply 193-4. [DOI: 10.1016/j.tics.2010.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 02/16/2010] [Accepted: 03/02/2010] [Indexed: 11/19/2022]
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