Implicit awareness in anosognosia for hemiplegia: unconscious interference without conscious re-representation

What I think she thinks about my paralysed body: Social inferences about disability-related content in anosognosia for hemiplegia

The neuropsychological disorder of anosognosia for hemiplegia (AHP) can offer unique insights into the neurocognitive processes of body consciousness and representation. Previous studies have found associations between selective social cognition deficits and anosognosia. In this study, we examined how such social cognition deficits may directly interact with representations of one's body as disabled in AHP. We used a modified set of previously validated Theory of Mind (ToM) stories to create disability-related content that was related to post-stroke paralysis and to investigate differences between right hemisphere damage patients with (n = 19) and without (n = 19) AHP. We expected AHP patients to perform worse than controls when trying to infer paralysis-related mental states in the paralysis-related ToM stories and explored whether such differences depended on the inference patients were asked to perform (e.g. self or other referent perspective-taking). Using an advanced structural neuroimaging technique, we expected selective social cognitive deficits to be associated with posterior parietal cortex lesions and deficits in self-referent perspective-taking in paralysis-related mentalising to be associated with frontoparietal disconnections. Group- and individual-level results revealed that AHP patients performed worse than HP controls when trying to infer paralysis-related mental states. Exploratory lesion analysis results revealed some of the hypothesised lesions, but also unexpected white matter disconnections in the posterior body and splenium of the corpus collosum associated with a self-referent perspective-taking in paralysis-related ToM stories. The study has implications for the multi-layered nature of body awareness, including abstract, social perspectives and beliefs about the body.

An Overview of the Bodily Awareness Representation and Interoception: Insights and Progress in the Field of Neurorehabilitation Research

In the last two decades, the scientific literature on so-called body representations has been increasing, and the notion of body awareness (BA) is particularly interesting for neurorehabilitation. In this article, we present results derived from recent studies on this representation, considering the different definitions and explicative models proposed as well as the empirical settings used to test it, providing an extensive overview of these issues. This article discusses the challenge of understanding how we integrate the sensory experiences of proprioception (knowing where our body is in space) and interoception (sensing internal bodily sensations, like hunger of thirst) with our perception of self. This is a difficult problem to analyze because our awareness of our body is inherently linked to our perspective, since the body is the means through which we interact with the world. Presenting the different viewpoints offered by recent theories on this concern, we highlighted that the neurorehabilitation and psychiatric settings offer two important fields useful for the study of BA because in them it is possible to analyze bodily representations by inducing/observing a controlled discrepancy between dysfunctional content and sensory inputs.

Subcortical contributions to the sense of body ownership

The sense of body ownership (i.e. the feeling that our body or its parts belong to us) plays a key role in bodily self-consciousness and is believed to stem from multisensory integration. Experimental paradigms such as the rubber hand illusion have been developed to allow the controlled manipulation of body ownership in laboratory settings, providing effective tools for investigating malleability in the sense of body ownership and the boundaries that distinguish self from other. Neuroimaging studies of body ownership converge on the involvement of several cortical regions, including the premotor cortex and posterior parietal cortex. However, relatively less attention has been paid to subcortical structures that may also contribute to body ownership perception, such as the cerebellum and putamen. Here, on the basis of neuroimaging and neuropsychological observations, we provide an overview of relevant subcortical regions and consider their potential role in generating and maintaining a sense of ownership over the body. We also suggest novel avenues for future research targeting the role of subcortical regions in making sense of the body as our own.

Key constructs of body awareness impairments post-stroke: a scoping review of assessment tools and interventions

PURPOSE

To summarise body awareness assessment tools and interventions relevant for stroke rehabilitation using a framework that categorises key body awareness constructs, disorders and impairments.

MATERIALS AND METHODS

Online electronic databases and trial registries were searched from inception until July 2021, in addition to hand searching reference lists of included studies and reviews. Study selection included any study design where the investigation involved assessing and/or intervening in body awareness following stroke. Data were extracted based on predefined criteria by two independent reviewers and mapped to the emergent framework.

RESULTS

The final analysis included 144 papers that reported 43 assessment tools and 8 types of interventions for body awareness. Consensus was reached on a synthesised body awareness framework. This comprised specific impairments and disorders, constructs, sub-categories and main categories leading to the overarching term of body awareness. Clinical and psychometric properties of the assessment tools were not reported or poorly evaluated, and the interventions lacked robust study designs and rigorous methods.

CONCLUSIONS

The framework produced will enable future research and clinical practice to be based on consistent concepts and definitions. Clinicians can also use this information to cautiously select assessment tools and/or interventions but are reminded of the limitations identified in this review.Implications for rehabilitationThere is limited understanding, compounded by inconsistent terminology and definitions regarding body awareness after stroke.A synthesized framework to define key constructs and definitions of body awareness is proposed.Assessment tools and interventions reported in the literature are mapped to the proposed framework.Psychometric properties of available tools are reported.Significant work remains to refine concepts of body awareness, develop and evaluate assessment tools and interventions.

Network Localization of Awareness in Visual and Motor Anosognosia

OBJECTIVE

Unawareness of a deficit, anosognosia, can occur for visual or motor deficits and lends insight into awareness itself; however, lesions associated with anosognosia occur in many different brain locations.

METHODS

We analyzed 267 lesion locations associated with either vision loss (with and without awareness) or weakness (with and without awareness). The network of brain regions connected to each lesion location was computed using resting-state functional connectivity from 1,000 healthy subjects. Both domain specific and cross-modal associations with awareness were identified.

RESULTS

The domain-specific network for visual anosognosia demonstrated connectivity to visual association cortex and posterior cingulate while motor anosognosia was defined by insula, supplementary motor area, and anterior cingulate connectivity. A cross-modal anosognosia network was defined by connectivity to the hippocampus and precuneus (false discovery rate p < 0.05).

INTERPRETATION

Our results identify distinct network connections associated with visual and motor anosognosia and a shared, cross-modal network for awareness of deficits centered on memory-related brain structures. ANN NEUROL 2023;94:434-441.

Exploring impaired self-awareness of motor symptoms in Parkinson's disease: Resting-state fMRI correlates and the connection to mindfulness

OBJECTIVE

To further explore the phenomenon of impaired self-awareness of motor symptoms in patients with Parkinson's Disease by using an evaluated measurement approach applied in previous studies, while also examining its connection with dispositional mindfulness and possible correlates of functional connectivity.

BACKGROUND

Recently, the phenomenon of impaired self-awareness has been studied more intensively by applying different measurement and imaging methods. Existing literature also points towards a possible connection with mindfulness, which has not been examined in a cross-sectional study. There is no data available concerning correlates of functional connectivity.

METHODS

Non-demented patients with idiopathic Parkinson's Disease without severe depression were tested for impaired self-awareness for motor symptoms following a psychometrically evaluated approach. Mindfulness was measured by applying the German version of the Five Facet Mindfulness Questionnaire. A subset of eligible patients underwent functional MRI scanning. Spearman correlation analyses were performed to examine clinical data. Whole-brain voxelwise regressions between seed-based connectivity and behavioral measures were calculated to identify functional connectivity correlates of impaired self-awareness scores.

RESULTS

A total of 41 patients with Parkinson's Disease were included. 15 patients successfully underwent resting-state fMRI scanning. Up to 88% of patients showed signs of impaired self-awareness. Awareness for hypokinetic movements correlated with total mindfulness values and three facets, while awareness for dyskinetic movements did not. Three significant clusters between scores of impaired self-awareness in general and for dyskinetic movements were identified linking behavioral measures with the functional connectivity of the inferior frontal gyrus, the right insular cortex, the supplementary motor area, and the precentral gyrus among others. Impaired self-awareness for hypokinetic movements did not have any neural correlate.

CONCLUSIONS

Clinical data is comparable with results from previous studies applying the same structured approach to measure impaired self-awareness in Parkinson's Disease. Functional connectivity analyses were conducted for the first time to evaluate neural correlates thereof. This data does not support a connection between impaired self-awareness of motor symptoms and dispositional mindfulness.

Hemispheric Differences in Self-evaluation Errors of Upper Extremity Movement in Patients with Chronic Stroke

OBJECTIVE

There is growing evidence that the side of brain lesions results in distinct upper extremity deficits in motor control, movement behavior, and emotional and cognitive function poststroke. We investigated self-evaluation errors, which are the differences in scores between patient self-evaluation and clinician evaluations, and compared patients with left hemisphere damage (LHD) and right hemisphere damage (RHD) poststroke.

METHOD

Twenty-eight patients with chronic stroke (LHD = 16) performed the actual amount of the test twice with a one-week interval. We videotaped the participants' movements, and participants with stroke and evaluators graded the quality of movement scores by watching video recordings.

RESULTS

Self-evaluation errors were significantly lower in patients with LHD than in those with RHD (t = 2.350, p = .019). Interestingly, this error did not change after the clinician provided the correct score as feedback. Chi-squared analysis revealed that more patients with LHD underestimated their movements (χ² = 9.049, p = .002), while more patients with RHD overestimated (χ² = 7.429, p = .006) in the send evaluation. Furthermore, there were no correlations between self-evaluation error and age, cognitive function, physical impairment, ability to control emotions, or onset months poststroke.

CONCLUSIONS

Patients with stroke and therapists evaluated the same movements differently, and this can be dependent on hemispheric damage. Therapists might need to encourage patients with LHD who underestimate their movement to ensure continuous use of their more-affected arm. Patients with RHD who overestimate their movement might need treatment to overcome impaired self-awareness, such as video recordings, to protect from unexpected dangerous situations.

Temporal judgments of actions following unilateral brain damage

Sense of time is a complex construct, and its neural correlates remain to date in most part unknown. To complicate the frame, physical attributes of the stimulus, such as its intensity or movement, influence temporal perception. Although previous studies have shown that time perception can be compromised after a brain lesion, the evidence on the role of the left and right hemispheres are meager. In two experiments, the study explores the ability of temporal estimation of multi-second actions and non-biological movements in 33 patients suffering from unilateral brain lesion. Furthermore, the modulatory role of induced embodiment processes is investigated. The results reveal a joint contribution of the two hemispheres depending not only on different durations but also on the presence of actions. Indeed, the left hemisphere damaged patients find it difficult to estimate 4500 ms or longer durations, while the right hemisphere damaged patients fail in 3000 ms durations. Furthermore, the former fail when a biological action is shown, while the latter fail in non-biological movement. Embodiment processes have a modulatory effect only after right hemisphere lesions. Among neuropsychological variables, only spatial neglect influences estimation of non-biological movement.

Motor awareness: a model based on neurological syndromes

Motor awareness is a complex, multifaceted construct involving the awareness of both (i) one's motor state while executing a movement or remaining still and (ii) one's motor abilities. The analysis of neurological syndromes associated with motor disorders suggests the existence of various different components which are, however, integrated into a model of motor awareness. These components are: (i) motor intention, namely, a conscious desire to perform an action; (ii) motor monitoring and error recognition, that is, the capacity to check the execution of the action and identify motor errors; and (iii) a general awareness of one's own motor abilities and deficits, that is, the capacity to recognize the general state of one's motor abilities about the performance of specific actions and the potential consequences of motor impairment. Neuroanatomical correlates involving the parietal and insular cortices, the medial and lateral frontal regions, and subcortical structures (basal ganglia and limbic system) support this multi-component model. Specific damage (or disconnections) to these structures results in a number of different disorders in motor awareness, such as anosognosia for hemiplegia and apraxia, and a number of symptoms which are specific to motor intention disorders (e.g., the Anarchic Hand Syndrome and Tourette's Syndrome) or motor monitoring (e.g., Parkinson's and Huntington's diseases). All of these clinical conditions are discussed in the light of a motor awareness model.

The sense of agency for brain disorders: A comprehensive review and proposed framework

Sense of Agency (SoA) refers to the feeling of control over voluntary actions and the outcomes of those actions. Several brain disorders are characterized by an abnormal SoA. To date, there is no robust treatment for aberrant agency across disorders; this is, in large part, due to gaps in our understanding of the cognitive mechanisms and neural correlates of the SoA. This apparent gap stems from a lack of synthesis in established findings. As such, the current review reconciles previously established findings into a novel neurocognitive framework for future investigations of the SoA in brain disorders, which we term the Agency in Brain Disorders Framework (ABDF). In doing so, we highlight key top-down and bottom-up cues that contribute to agency prospectively (i.e., prior to action execution) and retrospectively (i.e., after action execution). We then examine brain disorders, including schizophrenia, autism spectrum disorders (ASD), obsessive-compulsive disorders (OCD), and cortico-basal syndrome (CBS), within the ABDF, to demonstrate its potential utility in investigating neurocognitive mechanisms underlying phenotypically variable presentations of the SoA in brain disorders.

Hyperreactivity to uncertainty is a key feature of subjective cognitive impairment

With an increasingly ageing global population, more people are presenting with concerns about their cognitive function, but not all have an underlying neurodegenerative diagnosis. Subjective cognitive impairment (SCI) is a common condition describing self-reported deficits in cognition without objective evidence of cognitive impairment. Many individuals with SCI suffer from depression and anxiety, which have been hypothesised to account for their cognitive complaints. Despite this association between SCI and affective features, the cognitive and brain mechanisms underlying SCI are poorly understood. Here, we show that people with SCI are hyperreactive to uncertainty and that this might be a key mechanism accounting for their affective burden. Twenty-seven individuals with SCI performed an information sampling task, where they could actively gather information prior to decisions. Across different conditions, SCI participants sampled faster and obtained more information than matched controls to resolve uncertainty. Remarkably, despite their ‘urgent’ sampling behaviour, SCI participants were able to maintain their efficiency. Hyperreactivity to uncertainty indexed by this sampling behaviour correlated with the severity of affective burden including depression and anxiety. Analysis of MRI resting functional connectivity revealed that SCI participants had stronger insular-hippocampal connectivity compared to controls, which also correlated with faster sampling. These results suggest that altered uncertainty processing is a key mechanism underlying the psycho-cognitive manifestations in SCI and implicate a specific brain network target for future treatment.

Eliciting Implicit Awareness in Alzheimer’s Disease and Mild Cognitive Impairment: A Task-Based Functional MRI Study

Background

Recent models of anosognosia in dementia have suggested the existence of an implicit component of self-awareness about one’s cognitive impairment that may remain preserved and continue to regulate behavioral, affective, and cognitive responses even in people who do not show an explicit awareness of their difficulties. Behavioral studies have used different strategies to demonstrate implicit awareness in patients with anosognosia, but no neuroimaging studies have yet investigated its neural bases.

Methods

Patients with amnestic mild cognitive impairment and dementia due to Alzheimer’s disease underwent functional magnetic resonance imaging (fMRI) during the execution of a color-naming task in which they were presented with neutral, negative, and dementia-related words (Dementia-Related Emotional Stroop).

Results

Twenty-one patients were recruited: 12 were classified as aware and 9 as unaware according to anosognosia scales (based on clinical judgment and patient-caregiver discrepancy). Behavioral results showed that aware patients took the longest time to process dementia-related words, although differences between word types were not significant, limiting interpretation of behavioral results. Imaging results showed that patients with preserved explicit awareness had a small positive differential activation of the posterior cingulate cortex (PCC) for the dementia-related words condition compared to the negative words, suggesting attribution of emotional valence to both conditions. PCC differential activation was instead negative in unaware patients, i.e., lower for dementia-related words relative to negative-words. In addition, the more negative the differential activation, the lower was the Stroop effect measuring implicit awareness.

Conclusion

Posterior cingulate cortex preserved response to dementia-related stimuli may be a marker of preserved implicit self-awareness.

Pilot Study of Mindfulness Training on the Self-Awareness of Motor Symptoms in Parkinson's Disease - A Randomized Controlled Trial

Objective: This study aims to evaluate feasibility and effects of a newly developed mindfulness intervention tailored to specific needs of patients with Parkinson’s disease (PD).

Background: The phenomenon of impaired self-awareness of motor symptoms (ISAm) in PD might be reduced by increasing patients’ mindfulness. A PD-specific mindfulness intervention has been developed and evaluated as a potential treatment option: IPSUM (“Insight into Parkinson’s Disease Symptoms by using Mindfulness”).

Methods: IPSUM’s effectiveness is evaluated by comparing an intervention with a waitlist-control group. Applying a pre-post design, patients were assessed before, directly after and 8weeks after treatment. The primary outcome was the change in a quantitative ISAm score from baseline to post-assessment. Secondary outcome measures were PD-related affective changes and neuropsychological test performance. Feasibility was evaluated via feedback forms.

Results: In total, 30 non-depressed and non-demented PD patients were included (intervention: n=14, waitlist-control: n=16). ISAm score did not change significantly, but the training group showed greater performance in sustained attention and language tasks over time. Additional changes included greater mindfulness as well as less sleeping problems and anxiety. Cognitive disturbances, apathy, and sleeping problems worsened only in the waitlist-control group. Patients’ feedback regarding the training concept and material was excellent.

Conclusion: Insight into Parkinson’s Disease Symptoms by using Mindfulness has not been capable of reducing ISAm in PD patients but appears to be a feasible and effective concept to, among others, support mental health in the mid-term. It has to be noted though that the study was stopped beforehand because of the SARS CoV-2 pandemic. The lack of findings might therefore be caused by a lack of statistical power. The need for further research to better understand the mechanisms of ISAm and its connection to mindfulness in PD is highlighted.

The relations between cognitive and motivational components of anosognosia for left-sided hemiplegia and the right hemisphere dominance for emotions: A historical survey

Since the description of anosognosia for hemiplegia by Babinski (who also stressed the links between anosognosia and right hemisphere damage) both motivational and cognitive mechanisms have been advanced to explain this awareness disorder. In this review I will discuss first the neurophysiological mechanisms that can impede the discovery of the motor deficits contralateral to the brain lesion and then suggest that some instances of anosognosia for left-sided hemiplegia may also be due to motivational mechanisms of denial. Among the cognitive mechanisms, sensory feedback and intentional feed-forward disorders can lead to a poor awareness of the motor defects, whereas denial mechanisms could result from an interaction between the right hemisphere dominance for emotions and the anxiety raised by the catastrophic consequences of the brain damage. In particular, a maladaptive reaction to the personal implications of the brain lesion could be revealed by the presence of an implicit acknowledgement of the motor defect.

Updating beliefs beyond the here-and-now: the counter-factual self in anosognosia for hemiplegia

The syndrome of anosognosia for hemiplegia, or the lack of awareness for one’s paralysis following right hemisphere stroke, can provide unique insights into the neurocognitive mechanisms of self-awareness. Yet it remains unclear whether anosognosia for hemiplegia is a modality-specific deficit of sensorimotor monitoring, or whether domain-general processes of attention and belief-updating converge to cause anosognosia for hemiplegia. Using a Bayesian learning framework, we formalized and empirically investigated the hypothesis that failures to update anosognosic beliefs can be explained by abnormalities in the relative uncertainty (i.e. precision) ascribed to prior beliefs versus sensory information in different contexts. We designed a new motor belief-updating task that manipulated both the temporal (prospective and retrospective) and spatial (hemispace most affected by inattention and hemispace less affected by inattention) conditions in which beliefs had to be updated, and we validated its sensitivity to anosognosia for hemiplegia in 26 patients with right hemisphere stroke. We then computed and empirically tested two different Bayesian predictors of prospective beliefs using two proxies for precision in anosognosia for hemiplegia patients: (i) standardized, neuropsychological measures of objective attention abilities, i.e. visuospatial neglect scores and (ii) subjective uncertainty reports, i.e. confidence ratings. Our results suggest that while neglect does not affect local, sensorimotor error monitoring, it does seem to affect the degree to which observed errors are used to update more general, prospective beliefs about counterfactual motor abilities in anosognosia for hemiplegia. Difficulties in such ‘counterfactual’ belief-updating were associated with disruptions in tracts of the ventral attentional network (i.e. superior longitudinal fasciculus connecting the temporo-parietal junction and ventral frontal cortex) and associated lesions to the insula, inferior parietal cortex and superior temporal regions. These results suggest that self-awareness extends beyond local, retrospective monitoring, requiring also salience-based, convergence of beliefs about the self that go beyond the ‘here-and-now’ of sensorimotor experience.

The Phenomenology of Acute Anosognosia for Hemiplegia

OBJECTIVE

After attempting to move a plegic limb, patients with anosognosia for hemiplegia (AHP) may claim that limb movement occurred, even though the limb remained motionless. The authors investigated the characteristics, natural history, and anatomical basis of AHP phenomenology.

METHODS

Twenty-nine right-hemisphere stroke patients with acute anosognosia for hemiplegia (AHP) were prospectively assessed for the presence and characteristics of movement claims and observable behavior during movement attempts.

RESULTS

AHP was transient, with the condition resolving in 68% of patients by 1 week. Patients made movement claims during 31% of unilateral movement attempts and 50% of bilateral movement attempts. Movement claims were idiosyncratic, lacked internal consistency within individual patients, and even dissociated from explicit denial, as several patients made movement claims after they began to explicitly acknowledge hemiplegia. Observable behavior during movement attempts revealed allochiria (moving the right arm instead of the left) in 31% of patients, signs of implicit knowledge of weakness in 24%, and intact intention in 34%. Lesion analysis revealed that allochiria was associated with inferior right parietal lobe damage.

CONCLUSIONS

These results highlight that heterogeneity, phenomenological complexity, and transience are hallmarks of AHP. This advances clinical AHP assessment by showing that assessment of performance, rather than just verbal response, uncovers multiple dimensions of AHP. Allochiria emerges as an anatomically distinct subcomponent of the disorder. These findings also have theoretical implications, because they do not lend support to unitary pathogenic models proposing that illusions of movement or impaired intention form the basis of AHP. Most patients rapidly improve, which should invigorate the search for typical compensatory mechanisms underlying spontaneous recovery.

The Seven Selves of Dementia

The self is a complex and multifaceted phenomenon, encompassing a variety of cognitive processes and psychosocial influences. Considering this, there is a multiplicity of "selves," the current review suggesting that seven fundamental self-processes can be identified that further our understanding of the experience of dementia. These include (1) an embodied self, manifest as corporeal awareness; (2) an agentic self, related to being an agent and influencing life circumstances; (3) an implicit self, linked to non-conscious self-processing; (4) a critical self, which defines the core of self-identity; (5) a surrogate self, based on third-person perspective information; (6) an extended self, including external objects or existences that are incorporated into the self; and, finally, (7) an emergent self, a property of the self-processes that give rise to the sense of a unified self. These are discussed in relation to self-awareness and their use in making sense of the experience of dementia.

The Motor Unawareness Assessment (MUNA): A new tool for the assessment of Anosognosia for hemiplegia

Introduction: Anosognosia for hemiplegia (AHP) is a condition in which patients with paralysis are unaware of their motor deficits. Research into AHP is important for improving its treatment and providing insight into the neurocognitive mechanism of motor awareness. Unfortunately, most studies use assessments with widely recognized limitations.

The study aims at developing a psychometrically validated assessment of AHP.

Method: We developed a 40-item Motor Unawareness Assessment (MUNA) and administered it to 131 right-hemisphere stroke patients. Principal Component Analysis (PCA) was used to identify the underlying factor structure. Receiver Operating Characteristics (ROC) analysis was used to determine diagnostic cutoffs, and Area Under the Curve (AUC) analysis used to assess these cutoffs. Relationships with demographic, clinical and neuropsychological variables were explored.

Results: Five factors were identified: explicit motor awareness, implicit motor awareness, impaired sense of ownership, agency and illusory movement, and emotional reactions. Established cutoffs had excellent sensitivity and specificity. Clinical, neuropsychological and demographic variables did not predict overall MUNA score but were related to specific subcomponents.

Conclusion: The MUNA can differentiate various facets of AHP and provides a detailed profile of (un)awareness. The MUNA can therefore provide robust assessment for research purposes and assist clinicians when developing targeted rehabilitation.

Improving Self-Awareness of Motor Symptoms in Patients With Parkinson's Disease by Using Mindfulness - A Study Protocol for a Randomized Controlled Trial

Objective

This study aims to increase self-awareness in patients with Parkinson’s disease (PD) using a newly developed mindfulness-based intervention, tailored for the specific needs of PD patients. Its impact on self-awareness and patients’ daily lives is currently being evaluated.

Background

Recently, the phenomenon of impaired self-awareness for motor symptoms (ISAm) and some non-motor symptoms has been described in PD. ISAm can negatively influence patients’ daily lives, e.g., by affecting therapy adherence, and is therefore the main focus of this study. The main goal is the development of IPSUM (“Insight into Parkinson’s Disease Symptoms by using Mindfulness”), a PD-specific intervention for increasing patients’ mindfulness and thereby reducing ISAm.

Methods

The effectiveness of IPSUM is evaluated by comparison of an intervention group with a waitlist-control group. A pre-post design with an additional 8-week follow-up measurement is applied, resulting in three measurement points: before, directly after and 8 weeks after completing the intervention protocol. In total, up to 180 non-depressed PD patients without severe cognitive impairment (non-demented) will be included. The primary outcome is a quantitative score for measuring ISAm. Secondary outcome measures are affective changes, neuropsychological performance and self-awareness of cognition. At pre- and post-measurement an fMRI scan is performed to connect behavioral and neurobiological findings. At post- and follow-up-measurement each patient will take part in a semi-structured interview to explore IPSUM’s impact on self-awareness and patients’ everyday lives.

Results

The conception of the intervention protocol is finished, the resulting 8-week program is presented in detail. It has successfully been tested in the first group of patients, their feedback so far was quite promising. Recruitment is ongoing and a first interim analysis will be performed once 30 patients have completed IPSUM.

Conclusion

For the first time, the intervention protocol of IPSUM has successfully been tested in a group of PD patients. As the study goes on, more quantitative data is collected for statistical analyses to evaluate its effectiveness. More qualitative data is collected to evaluate feasibility and effectiveness. We hope for this intervention to be capable of reducing the patients’ ISAm and improving their quality of life on many levels.

Hippocampal diaschisis contributes to anosognosia for hemiplegia: Evidence from lesion network-symptom-mapping

Anosognosia for hemiplegia (AHP) is known to be associated with lesions to the motor system combined with varying lesions to the right insula, premotor cortex, parietal lobe or hippocampus. Due to this widespread cortical lesion distribution, AHP can be understood best as a network disorder. We used lesion maps and behavioral data (n ​= ​49) from two previous studies on AHP and performed a lesion network-symptom-mapping (LNSM) analysis. This new approach permits the identification of relationships between behavior and regions connected to the lesion site based on normative functional connectome data. In a first step, using ordinary voxel-based lesion-symptom mapping, we found an association of AHP with lesions in the right posterior insula. This is in accordance with previous studies. Applying LNSM, we were able to additionally identify a region in the right posterior hippocampus where AHP was associated with significantly higher normative lesion connectivity. Notably, this region was spared by infarction in all patients. We therefore argue that remote neuronal dysfunction caused by disrupted functional connections between the lesion site and the hippocampus (i.e. diaschisis) contributed to the phenotype of AHP. An indirect affection of the hippocampus may lead to memory deficits which, in turn, impair the stable encoding of updated beliefs on the bodily state thus contributing to the multifactorial phenomenon of AHP.

Anosognosia for hemiplegia as a tripartite disconnection syndrome

The syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into the neurocognitive processes of motor awareness. Yet, prior studies have only explored predominately discreet lesions. Using advanced structural neuroimaging methods in 174 patients with a right-hemisphere stroke, we were able to identify three neural systems that contribute to AHP, when disconnected or directly damaged: the (i) premotor loop (ii) limbic system, and (iii) ventral attentional network. Our results suggest that human motor awareness is contingent on the joint contribution of these three systems.

Impaired Self-Awareness of Motor Disturbances in Parkinson's Disease

Traditionally, anosognosia for cognitive or motor impairments in patients with Parkinson's disease (PD) was viewed as unlikely unless the patient was demented. More recent research has suggested that a portion of non-demented PD patients (30%-50%) in fact have impaired subjective awareness (ISA) of their motor impairments (ISAm). This empirical finding has implications for the clinical neuropsychological examination of PD patients and raises theoretical questions relevant to the broader study of anosognosia seen in other patient groups. The purpose of this paper is to primarily review our own research in this area and to summarize research findings of other investigators who have examined ISA in PD patients. Our secondary goal is to demonstrate the relevance of assessing ISA when conducting a neuropsychological examination of PD patients. Our findings suggest ISAm in PD patients is related to motor signs of right hemispheric dysfunction, but the brain imaging correlates of ISA for hypokinesias appear different than those obtained for ISA for dyskinesia in this patient group.

Computational Neuropsychology and Bayesian Inference

Computational theories of brain function have become very influential in neuroscience. They have facilitated the growth of formal approaches to disease, particularly in psychiatric research. In this paper, we provide a narrative review of the body of computational research addressing neuropsychological syndromes, and focus on those that employ Bayesian frameworks. Bayesian approaches to understanding brain function formulate perception and action as inferential processes. These inferences combine ‘prior’ beliefs with a generative (predictive) model to explain the causes of sensations. Under this view, neuropsychological deficits can be thought of as false inferences that arise due to aberrant prior beliefs (that are poor fits to the real world). This draws upon the notion of a Bayes optimal pathology – optimal inference with suboptimal priors – and provides a means for computational phenotyping. In principle, any given neuropsychological disorder could be characterized by the set of prior beliefs that would make a patient’s behavior appear Bayes optimal. We start with an overview of some key theoretical constructs and use these to motivate a form of computational neuropsychology that relates anatomical structures in the brain to the computations they perform. Throughout, we draw upon computational accounts of neuropsychological syndromes. These are selected to emphasize the key features of a Bayesian approach, and the possible types of pathological prior that may be present. They range from visual neglect through hallucinations to autism. Through these illustrative examples, we review the use of Bayesian approaches to understand the link between biology and computation that is at the heart of neuropsychology.

Unawareness for Motor Impairment and Distorted Perception of Task Difficulty

OBJECTIVES

Anosognosia for motor impairment is a complex syndrome that can manifest itself under different forms, guiding patients' behavior and task decisions. However, current diagnostic tools tend to evaluate only more explicit aspects of anosognosia (asking the patients about their motor abilities) and fail to address more subtle features of awareness. We have developed a new assessment measure, the ECT (Errand Choice Test), where patients are asked to judge task difficulty rather than estimate their own impairment.

METHODS

We assessed awareness in a group of 73 unilateral left- and right-brain damaged (30 LBD and 43 RBD, respectively) patients by means of the VATAm, which explicitly requires them to evaluate their own motor abilities, and the ECT. A control group of 65 healthy volunteers was asked to perform the ECT under two conditions: Current condition (i.e., using both hands) and Simulated conditions (i.e., simulating hemiplegia).

RESULTS

A total of 27% of the patients showed different performance on the VATAm and ECT, 21% of the patients showing lack of awareness only on VATAm and 6% only on ECT. Moreover, despite the ECT identified a higher frequency of anosognosia after RBD (33.3%) than LBD (27.6%), this hemispheric asymmetry was not significant. Remarkably, anosognosic patients performed very similarly to controls in the "current condition", suggesting that anosognosic patients' ability to perceive the complexity of each task per se is not altered.

CONCLUSION

Different methods may be able to tackle different aspects of awareness and the ECT proved to be able to detect less evident forms of awareness. (JINS, 2018, 24, 45-56).

Anosognosia, denial of illness and the right hemisphere dominance for emotions: Some historical and clinical notes

Poor disease awareness ('anosognosia') is often observed in patients with various disabilities caused by brain damage. The lack of disease awareness can be due to the disruption of specific cognitive mechanisms and the development of psychodynamic mechanisms of denial. The aim of this paper is to review how these phenomena were discovered and evolved over time and to consider the relationships between them and the right hemisphere dominance for emotions. It is not clear whether the term 'anosognosia' refers to a basic mechanism that can explain similar awareness defects in different behavioural domains or whether it must be viewed as a multifaceted phenomenon in which both the disruption of cognitive or sensorimotor mechanisms and the emergence of motivational factors can play different roles in various forms of disease unawareness and in different kinds of 'anosognosic' patients.

Investigating Behavioral and Psychophysiological Reactions to Conflict-Related and Individualized Stimuli as Potential Correlates of Repression

Background: Repression is considered as a central defense mechanism in psychodynamic theory. It refers to the process by which "unbearable" mental contents (e.g., those related to internal conflicts) are kept out of consciousness. The process of repression is probably closely related to concepts of emotion regulation derived from a different theoretical background. This relationship is particularly relevant because it relates repression to current research in the affective neurosciences as well as to experimental studies on emotion regulation. Due to its complex and highly individual nature, repression has been notoriously difficult to investigate. We investigated repression with an individualized experiment in healthy subjects in order to establish methods to study repression in clinical populations. To this end we operationalized repression using individualized experimental conditions, and then studied potential behavioral [memory and reaction time (RT)] and psychophysiological correlates [skin conductance response (SCR)]. Method: Twenty-nine healthy female subjects were asked to freely associate to individualized cue sentences. Sentences were generated from individual psychodynamic interviews based on operationlized psychodynamic diagnosis (OPD), and were comprised of three different types: positive, negative non-conflictual, and negative conflict-related sentences. Subjects were asked to name the first three associations coming into their mind. Afterward, the remaining time was used for free association. SCR during each association trial and RT of the first given association were recorded. The memory for the first three associations was subsequently tested in an unexpected recall. Results: Associations to conflict-related cue sentences were associated with longer RTs and increased SCRs. Moreover, the unexpected recall task showed memory for these associations to be reduced. Conclusion: We interpret these findings as possible correlates of repression, in line with a history of experimental research into repression using non-individualized cues. Consequently, we suggest that this experimental paradigm could serve to investigate repression in clinical populations.

Investigating structure and function in the healthy human brain: validity of acute versus chronic lesion-symptom mapping

Modern voxel-based lesion-symptom mapping (VLSM) analyses techniques provide powerful tools to examine the relationship between structure and function of the healthy human brain. However, there is still uncertainty on the type of and the appropriate time point of imaging and of behavioral testing for such analyses. Here we tested the validity of the three most common combinations of structural imaging data and behavioral scores used in VLSM analyses. Given the established knowledge about the neural substrate of the primary motor system in humans, we asked the mundane question of where the motor system is represented in the normal human brain, analyzing individual arm motor function of 60 unselected stroke patients. Only the combination of acute behavioral scores and acute structural imaging precisely identified the principal brain area for the emergence of hemiparesis after stroke, i.e., the corticospinal tract (CST). In contrast, VLSM analyses based on chronic behavior-in combination with either chronic or acute imaging-required the exclusion of patients who had recovered from an initial paresis to reveal valid anatomical results. Thus, if the primary research aim of a VLSM lesion analysis is to uncover the neural substrates of a certain function in the healthy human brain and if no longitudinal designs with repeated evaluations are planned, the combination of acute imaging and behavior represents the ideal dataset.

Ownership illusions in patients with body delusions: Different neural profiles of visual capture and disownership

The various neurocognitive processes contributing to the sense of body ownership have been investigated extensively in healthy participants, but studies in neurological patients can shed unique light into such phenomena. Here, we aimed to investigate whether visual capture by a fake hand (without any synchronous or asynchronous tactile stimulation) affects body ownership in a group of hemiplegic patients with or without disturbed sensation of limb ownership (DSO) following damage to the right hemisphere. We recruited 31 consecutive patients, including seven patients with DSO. The majority of our patients (64.5% overall and up to 86% of the patients with DSO) experienced strong feelings of ownership over a rubber hand within 15 sec following mere visual exposure, which correlated with the degree of proprioceptive deficits across groups and in the DSO group. Using voxel-based lesion-symptom mapping analysis, we were able to identify lesions associated with this pathological visual capture effect in a selective fronto-parietal network, including significant voxels (p < .05) in the frontal operculum and the inferior frontal gyrus. By contrast, lesions associated with DSO involved more posterior lesions, including the right temporoparietal junction and a large area of the supramarginal gyrus, and to a lesser degree the middle frontal gyrus. Thus, this study suggests that our sense of ownership includes dissociable mechanisms of multisensory integration.

Discrepancies among Measures of Executive Functioning in a Subsample of Young Adult Survivors of Childhood Brain Tumor: Associations with Treatment Intensity

OBJECTIVES

Treatments for childhood brain tumors (BT) confer substantial risks to neurological development and contribute to neuropsychological deficits in young adulthood. Evidence suggests that individuals who experience more significant neurological insult may lack insight into their neurocognitive limitations. The present study compared survivor, mother, and performance-based estimates of executive functioning (EF), and their associations with treatment intensity history in a subsample of young adult survivors of childhood BTs.

METHODS

Thirty-four survivors (52.9% female), aged 18 to 30 years (M=23.5; SD=3.4), 16.1 years post-diagnosis (SD=5.9), were administered self-report and performance-based EF measures. Mothers also rated survivor EF skills. Survivors were classified by treatment intensity history into Minimal, Average/Moderate, or Intensive/Most-Intensive groups. Discrepancies among survivor, mother, and performance-based EF estimates were compared.

RESULTS

Survivor-reported and performance-based measures were not correlated, although significant associations were found between mother-reported and performance measures. Survivors in the Intensive/Most-Intensive treatment group evidenced the greatest score discrepancies, reporting less executive dysfunction relative to mother-reported F(2,31)=7.81, p.05).

CONCLUSIONS

There may be a lack of agreement among survivor, mother, and performance-based estimates of EF skills in young adult survivors of childhood BT, and these discrepancies may be associated with treatment intensity history. Neuropsychologists should use a multi-method, multi-reporter approach to assessment of EF in this population. Providers also should be aware of these discrepancies as they may be a barrier to intervention efforts. (JINS, 2016, 22, 900-910).

Mentalizing the body: spatial and social cognition in anosognosia for hemiplegia

Following right-hemisphere damage, a specific disorder of motor awareness can occur called anosognosia for hemiplegia, i.e. the denial of motor deficits contralateral to a brain lesion. The study of anosognosia can offer unique insights into the neurocognitive basis of awareness. Typically, however, awareness is assessed as a first person judgement and the ability of patients to think about their bodies in more 'objective' (third person) terms is not directly assessed. This may be important as right-hemisphere spatial abilities may underlie our ability to take third person perspectives. This possibility was assessed for the first time in the present study. We investigated third person perspective taking using both visuospatial and verbal tasks in right-hemisphere stroke patients with anosognosia (n = 15) and without anosognosia (n = 15), as well as neurologically healthy control subjects (n = 15). The anosognosic group performed worse than both control groups when having to perform the tasks from a third versus a first person perspective. Individual analysis further revealed a classical dissociation between most anosognosic patients and control subjects in mental (but not visuospatial) third person perspective taking abilities. Finally, the severity of unawareness in anosognosia patients was correlated to greater impairments in such third person, mental perspective taking abilities (but not visuospatial perspective taking). In voxel-based lesion mapping we also identified the lesion sites linked with such deficits, including some brain areas previously associated with inhibition, perspective taking and mentalizing, such as the inferior and middle frontal gyri, as well as the supramarginal and superior temporal gyri. These results suggest that neurocognitive deficits in mental perspective taking may contribute to anosognosia and provide novel insights regarding the relation between self-awareness and social cognition.

Implicit and explicit self-related processing in relation to insight in patients with schizophrenia

INTRODUCTION

Self-related processing (SRP) has been associated with clinical and cognitive insight. We investigated the relationship between implicit SRP (ISRP) and explicit SRP (ESRP) and insight. We first hypothesised that impaired insight is associated with the extent to which implicit feedback is incorporated in the self-image and subsequently influences behaviour. Second, we hypothesised that impaired insight is related to the way patients handle explicit feedback and use it to guide subsequent behaviour, therefore we expected to find a positive relationship between level of insight and the explicit self-related processing task.

METHODS

Thirty-four schizophrenia patients and 23 healthy controls participated in the study. Patients were assessed with the Schedule for the Assessment of Insight-Expanded and the Beck Cognitive Insight Scale. ISRP was measured using a working memory two-back priming task. ESRP was measured with an adapted version of the Wisconsin Card Sorting Task where patients received explicit feedback on their performance.

RESULTS

Cognitive insight, but not clinical insight, was positively associated with ISRP after implicit positive cues. Both clinical and cognitive insight were positively associated with the ability to adjust performance upon receiving explicit feedback, though cognitive insight was more strongly associated with overall task performance.

CONCLUSIONS

Priming with positive cues improved performance on a working memory task in patients with good cognitive insight, but worsened performance in patients with impaired cognitive insight. Furthermore, our findings suggest that the ability to adequately use feedback may be a specific capacity that is related to insight.

The affective modulation of motor awareness in anosognosia for hemiplegia: behavioural and lesion evidence

The possible role of emotion in anosognosia for hemiplegia (i.e., denial of motor deficits contralateral to a brain lesion), has long been debated between psychodynamic and neurocognitive theories. However, there are only a handful of case studies focussing on this topic, and the precise role of emotion in anosognosia for hemiplegia requires empirical investigation. In the present study, we aimed to investigate how negative and positive emotions influence motor awareness in anosognosia. Positive and negative emotions were induced under carefully-controlled experimental conditions in right-hemisphere stroke patients with anosognosia for hemiplegia (n = 11) and controls with clinically normal awareness (n = 10). Only the negative, emotion induction condition resulted in a significant improvement of motor awareness in anosognosic patients compared to controls; the positive emotion induction did not. Using lesion overlay and voxel-based lesion-symptom mapping approaches, we also investigated the brain lesions associated with the diagnosis of anosognosia, as well as with performance on the experimental task. Anatomical areas that are commonly damaged in AHP included the right-hemisphere motor and sensory cortices, the inferior frontal cortex, and the insula. Additionally, the insula, putamen and anterior periventricular white matter were associated with less awareness change following the negative emotion induction. This study suggests that motor unawareness and the observed lack of negative emotions about one's disabilities cannot be adequately explained by either purely motivational or neurocognitive accounts. Instead, we propose an integrative account in which insular and striatal lesions result in weak interoceptive and motivational signals. These deficits lead to faulty inferences about the self, involving a difficulty to personalise new sensorimotor information, and an abnormal adherence to premorbid beliefs about the body.

Neuroanatomical correlates of awareness of illness in patients with amnestic mild cognitive impairment who will or will not convert to Alzheimer's disease

BACKGROUND

Awareness of cognitive deficits may be reduced in mild cognitive impairment (MCI). This may have a detrimental effect on illness course and may be a predictor of subsequent conversion to AD. Although neuropsychological correlates have been widely investigated, no evidence of a neuroanatomical basis of the phenomenon has been reported yet. This study was aimed at investigating the neuroanatomical correlates of deficit awareness in amnestic MCI to determine whether they constitute risk factors for conversion to AD.

METHOD

A sample of 36 first-diagnosis amnestic MCI patients were followed for five years. At the first diagnostic visit they were administered an extensive diagnostic and clinical procedure and the Memory Insight Questionnaire (MIQ), measuring a total index and four sub-indices, to investigate awareness of deficits in dementia; they also underwent a high resolution T1-weighted Magnetic Resonance Imaging (MRI) investigation. Grey matter brain volumes were analysed on a voxel-by-voxel basis using Statistical Parametric Mapping 8. Data of 10 converter patients (CONV) and those of 26 non converter patients (NOCONV) were analysed using multiple regression models.

RESULTS

At baseline, self-awareness of memory deficits was poorer in CONV compared to NOCONV. Furthermore, reduced awareness of cognitive deficits in CONV correlated with reduced grey matter volume of the anterior cingulate (memory deficit awareness), right pars triangularis of the inferior frontal cortex (memory deficit awareness) and cerebellar vermis (total awareness), whereas in NOCONV it correlated with reduced grey matter volume of left superior (total awareness) and middle (language deficit awareness) temporal areas. Further, at baseline self-awareness of memory deficits were poorer in CONV than in NOCONV.

CONCLUSIONS

Defective awareness of cognitive deficits is underpinned by different mechanisms in CONV and NOCONV amnestic MCI patients. Our data support the hypothesis that poor awareness of cognitive deficit is a predictor of subsequent conversion to AD.

Action-monitoring impairment in anosognosia for hemiplegia

Every movement begins with action programming, and ends with a produced effect. Anosognosia for hemiplegia (AH), involving unawareness of motor deficits after brain damage, is a striking but also poorly understood symptom in clinical neurology. It has been suggested that it may result from a combination of cognitive and sensorimotor dysfunctions, including impairments in monitoring motor action and detecting the mismatch between intention and outcome. Here we investigated the relationship between motor action awareness and monitoring of self-produced movements by using a motor imaginary task, which was performed with either the intact or the affected limb. We tested 10 right brain-damaged patients, including 5 with AH, in comparison with 5 healthy controls. In a first phase, participants were asked to either realize or imagine a movement with their right or left arm. In a subsequent recognition phase, the participants had to recall whether the movement was a realized or imagined and which arm was used. AH patients performed significantly worse relative to no-AH patients and healthy controls for the left movements. Specifically, we found that AH patients believed they had realized movements with their (paralyzed) left arm even when they failed in the left execution condition. However, they also made more errors for movements actually realized with the right hand. These findings confirm that impaired action monitoring may contribute to AHP. Furthermore, our results support the notion of an action control system integrating "feedforward" signals through a comparison process between the intention and execution of movement, but also indicate that monitoring deficits in AHP are not strictly unilateral. Combined together, dysfunction of motor comparator processes and more general monitoring deficits may add up to lead to unawareness of paralysis.

Anosognosia for hemianaesthesia: a voxel-based lesion-symptom mapping study

Brain-damaged patients affected by hemianaesthesia (i.e., the loss of tactile sensibility on the contralesional side of the body) may deny their deficits (i.e., anosognosia for tactile deficits) even reporting tactile experience when stimuli are delivered on the impaired side. So far, descriptive analysis on small samples of patients reported that the insular cortex, the internal/external capsule, the basal ganglia and the periventricular white matter would subserve anosognosia for hemianaesthesia. Here, we aimed at examining in depth the anatomo-functional nature of anosognosia for hemianaesthesia by means of a voxelwise statistical analysis. We compared two groups of left hemiplegic patients due to right brain damages differing only for the presence/absence of anosognosia for left hemianaesthesia. Our findings showed a lesional cluster confined mainly to the anterior part of the putamen. According to the current anatomical evidence on the neural basis of sensory expectancies, we suggested that anosognosia for hemianaesthesia might be explained as a failure to detect the mismatch between expected and actual tactile stimulation.

Anosognosia as motivated unawareness: the 'defence' hypothesis revisited

Anosognosia for hemiplegia has seen a century of almost continuous research, yet a definitive understanding of its mechanism remains elusive. Essentially, anosognosic patients hold quasi-delusional beliefs about their paralysed limbs, in spite of all the contrary evidence, repeated questioning, and logical argument. We review a range of findings suggesting that emotion and motivation play an important role in anosognosia. We conclude that anosognosia involves (amongst other things) a process of psychological defence. This conclusion stems from a wide variety of clinical and experimental investigations, including data on implicit awareness of deficit, fluctuations in awareness over time, and dramatic effects upon awareness of psychological interventions such as psychotherapy, reframing of the emotional consequences of the paralysis, and first versus third person perspectival manipulations. In addition, we review and refute the (eight) arguments historically raised against the 'defence' hypothesis, including the claim that a defence-based account cannot explain the lateralised nature of the disorder. We argue that damage to a well-established right-lateralised emotion regulation system, with links to psychological processes that appear to underpin allocentric spatial cognition, plays a key role in anosognosia (at least in some patients). We conclude with a discussion of implications for clinical practice.

Selective improvement of anosognosia for hemiplegia during transcranial direct current stimulation: a case report

Right brain damage patients may not complain of a left sided paralysis up to the point of denying it or even claiming of having just moved an otherwise paralyzed limb. This condition is known as anosognosia for hemiplegia (AHP). Recent behavioural experiments suggest that some residual intentionality might be preserved in patients with anosognosia and that the false belief of having moved originates from a failure to notice discrepancies between movement expectancies and the actual state of the motor system. This failure may be caused by a lack of afferent sensory information concerning the movement or alternatively by a direct dysfunction of the brain regions involved in actions' motor monitoring (i.e., the comparator system). Here we examined the effect of anodal transcranial direct current stimulation (tDCS) of the right premotor cortex in a patient with a bilateral lesion, involving predominantly the right hemisphere, and a dense unawareness for his left hemiplegia. During sham or anodal tDCS the patient was requested to judge his ability to perform simple motor actions (i) without actually executing the movement itself ("offline" condition) and after having performed a series of verbally cued finger opposition movements ("online" condition) with (i) eyes-closed or (ii) eyes-open. We found that anodal tDCS induces a significant remission of the false experience of movement only when the patient is requested to actually perform the movement with eyes open. Conversely, the patient's awareness does not improve in both the "offline" condition (in which the patient does not attempt to perform the movement) and in the "online" condition, when vision is precluded ("online" condition, eyes-closed). We conclude that the stimulation of the premotor cortex by tDCS activates brain regions involved in motor monitoring, temporary restoring the ability of the motor comparator system to correctly appreciate afferent information and build up a veridical motor awareness.

The Italian validation of the Anosognosia Questionnaire for Dementia in Alzheimer's disease

Although the Anosognosia Questionnaire-Dementia (AQ-D) is one of the main instruments for assessing awareness in Alzheimer's disease (AD), the normative data were until now limited to people from Argentina and Japan. This study aims to validate this instrument in an European context, in particular in an Italian sample. In a multicenter project (Verona, Padova, and Trapani), 130 patients with AD and their caregivers participated in the study. Psychometric characteristics of AQ-D are confirmed indicating that the scale permits the early identification of anosognosia and the correct care management of patients. Indeed, anosognosia results to be present also in patients with very mild AD (moderate: 44.44%; mild: 47.17%; and very mild: 23.73%). Moreover, the results indicate that deficits in awareness may vary in severity and that different types of anosognosia may be identified.

The case for neuropsychoanalysis: Why a dialogue with neuroscience is necessary but not sufficient for psychoanalysis

Recent advances in the cognitive, affective and social neurosciences have enabled these fields to study aspects of the mind that are central to psychoanalysis. These developments raise a number of possibilities for psychoanalysis. Can it engage the neurosciences in a productive and mutually enriching dialogue without compromising its own integrity and unique perspective? While many analysts welcome interdisciplinary exchanges with the neurosciences, termed neuropsychoanalysis, some have voiced concerns about their potentially deleterious effects on psychoanalytic theory and practice. In this paper we outline the development and aims of neuropsychoanalysis, and consider its reception in psychoanalysis and in the neurosciences. We then discuss some of the concerns raised within psychoanalysis, with particular emphasis on the epistemological foundations of neuropsychoanalysis. While this paper does not attempt to fully address the clinical applications of neuropsychoanalysis, we offer and discuss a brief case illustration in order to demonstrate that neuroscientific research findings can be used to enrich our models of the mind in ways that, in turn, may influence how analysts work with their patients. We will conclude that neuropsychoanalysis is grounded in the history of psychoanalysis, that it is part of the psychoanalytic worldview, and that it is necessary, albeit not sufficient, for the future viability of psychoanalysis.

Different levels of implicit emotional recognition in posterior cortical atrophy (PCA)

Previous single-case reports in posterior cortical atrophy (PCA) have shown preserved nonconscious visual recognition despite the absence of explicit recognition. In this study, we investigated three levels of visual recognition in both a female patient with PCA and a control group during the presentation of neutral, positive, and negative affective stimuli. Our results confirmed the profile of impaired explicit recognition and intact psychophysiological responses in the patient. In addition, she was able to implicitly recognize the valence and intensity of arousal of these stimuli. We suggest that implicit emotional awareness may mediates explicit and psychophysiological recognition in PCA.