Anosognosia for hemiplegia is the denial of neurologically-caused paralysis, and it often co-occurs with a number of distortions of belief and emotion such as somatoparaphrenia and an exaggeration of negative affect towards minor health complaints. The salience of these latter symptoms led early investigators to propose explanations of AHP which construed it as a process of motivated self-deception against the overwhelming anxiety and depression that knowledge of deficit would otherwise cause, and which was observed in hemiplegic patients without (...) the anosognosia. Since some influential critiques of this approach, however, theories of this kind have largely been rejected on the grounds that they are inappropriately “psychogenic.” What has replaced them are a class of theories which explain the lack of awareness in terms of neurocognitive deficit, with the deficit in question variously described by researchers as involving spatial awareness, motor control, and other capacities. In this paper I argue – contra claims in the literature – that the patterns of explanation which are characteristic of the psychodynamic theory are not incompatible in principle with the notion that the illness involves neurocognitive deficit. That means that these patterns of explanation can be preserved where they make good sense of the obscure attitudinal and emotional symptoms that occur in AHP – symptoms that are otherwise difficult to explain. I suggest some ways in which this fact could be accommodated by deficit theories of the illness which are based on motor deficit. (shrink)

Anosognosia for hemiplegia is a lack of awareness about paralysis following stroke. Recent explanations use a ‘forward model’ of movement to suggest that AHP patients fail to register discrepancies between internally- and externally-generated sensory information. We predicted that this failure would impair the ability to recall from memory whether information is internally- or externally-generated . Two experiments examined this prediction. Experiment 1 demonstrated that AHP patients exhibit a reality monitoring deficit for non-motor information , whilst hemiplegic controls without (...) anosognosia perform like age-matched healthy volunteers . Experiment 2 explored if this deficit occurs when AHP patients discriminate performed, imagined, or observed movement. Results showed impaired reality monitoring for movements in AHP and nonAHP patients relative to HVs. Findings suggest that reality monitoring processes not directly related to movement, together with a failure to reality monitor movements, contribute to the pathogenesis of AHP. (shrink)

Anosognosia is literally ‘unawareness of or failure to acknowledge one’s hemi- plegia or other disability’ (OED). Etymology would suggest the meaning ‘lack of knowledge of disease’ so that anosognosia would include any denial of impairment, such as denial of blindness (Anton’s syndrome). But Babinski, who introduced the term in 1914, applied it only to patients with hemiplegia who fail to acknowledge their paralysis. Most commonly, this is failure to acknowledge paralysis of the left side of the body (...) following damage to the right hemisphere of the brain. In this paper, we shall mainly be concerned with anosognosia for hemiplegia. But we shall also use the term ‘anosognosia’ in an inclusive way to encompass lack of knowledge or acknowledgement of any impairment. Indeed, in the construction ‘anosognosia for X’, X might even be anosognosia for some Y. (shrink)

The study of anosognosia has witnessed an unprecedented increase in interest over the last 20 years. This has resulted in numerous empirical investigations as well as theoretical writings on the nature of human consciousness and how disorders of the brain may influence the person's subjective awareness of a disturbed neurological or neuropsychological function. This edited text summarizes many of the advances that have taken place in the field of anosognosia. It reviews research findings on anosognosia for (...) class='Hi'>hemiplegia following stroke, Anton's syndrome, and a variety of disorders in which impaired self-awareness is common. It also provides suggestive guidelines for the management and rehabilitation of persons who have anosognosia or impaired self-awareness. (shrink)

Hysteria has been the subject of controversy for many years, with theorists arguing about whether it is best explained by a hidden organic cause or by malingering and deception. However, it has been shown that hysterical paralysis cannot be explained in any of these terms. With the recent development of cognitive psychiatry, one may understand psychiatric and organic delusions within the same conceptual framework. Here I contrast hysterical conversion with anosognosia. They are indeed remarkably similar, though the content of (...) their respective delusions is the opposite. In hysterical paralysis, patients are not aware of their preserved ability, whereas in anosognosia for hemiplegia, patients are not aware of their disability. Four main explanations have been provided to account for anosognosia: metacognitive, attentional, motor, and motivational views. I will apply each of these accounts to hysterical paralysis and show that, at each level, hysterical conversion is the reverse of anosognosia. I will suggest that hysterical paralysis results from the interaction between attentional somatosensory amplification and affective inhibition of action. (shrink)

This collection of essays focuses on the interface between delusions and self-deception. As pathologies of belief, delusions and self-deception raise many of the same challenges for those seeking to understand them. Are delusions and self-deception entirely distinct phenomena, or might some forms of self-deception also qualify as delusional? To what extent might models of self-deception and delusion share common factors? In what ways do affect and motivation enter into normal belief-formation, and how might they be implicated in self-deception and delusion? (...) The essays in this volume tackle these questions from both empirical and conceptual perspectives. Some contributors focus on the general question of how to locate self-deception and delusion within our taxonomy of psychological states. Some contributors ask whether particular delusions - such as the Capgras delusion or anosognosia for hemiplegia - might be explained by appeal to motivational and affective factors. And some contributors provide general models of motivated reasoning, against which theories of pathological belief-formation might be measured. (shrink)

The sense of embodiment is vital for self recognition. An examination of anosognosia for hemiplegia—the inability to recognise that one is paralysed down one side of one’s body—suggests the existence of ‘online’ and ‘offline’ representations of the body. Online representations of the body are representations of the body as it is currently, are newly constructed moment by moment and are directly “plugged into” current perception of the body. In contrast, offline representations of the body are representations of what (...) the body is usually like, are relatively stable and are constructed from online representations. This distinction is supported by an analysis of phantom limb—the feeling that an amputated limb is still present—phenomena. Initially it seems that the sense of embodiment may arise from either of these types of representation; however, an integrated representation of the body seems to be required. It is suggested information from vision and emotions is involved in generating these representations. A lack of access to online representations of the body does not necessarily lead to a loss in the sense of embodiment. An integrated offline representation of the body could account for the sense of embodiment and perform the functions attributed to this sense. (shrink)

This book proposes a novel and rigorous explanation of consciousness. It argues that the study of an aspect of our self-consciousness known as the ‘feeling of embodiment’ teaches us that there are two distinct phenomena to be targeted by an explanation of consciousness. First is an explanation of the phenomenal qualities – 'what it is like' – of the experience; and second is the subject's awareness of those qualities. Glenn Carruthers explores the phenomenal qualities of the feeling of embodiment using (...) the tools of quality spaces, as well as the subject's awareness of those qualities as a functionally emergent property of various kinds of processing of these spaces. Where much recent work on consciousness focuses on visual experience, this book rather draws evidence from the study of self-consciousness. Carruthers argues that in light of recent methodological discoveries, awareness must be explained in terms of the organization of multiple cognitive processes. The book offers an explanation of anomalous body representations and, from that, poses a more general theory of consciousness. Ultimately this book creates a hybrid account of consciousness that explains phenomenology and awareness using different tools. It will be of great interest to all scholars of psychology and philosophy as well as anyone interested in exploring the intricacies of how we experience our bodies, what we are and how we fit into the world. -/- . (shrink)

Anosognosia for visual deficits—cases where significant visual deficits go unnoticed—challenges the view that our own conscious experiences are what we know best. We review these widespread and striking failures of awareness. Anosognosia can occur with total blindness, visual abnormalities induced by brain lesions, and eye diseases. We show that anosognosia for visual deficits is surprisingly widespread. Building on previous accounts, we introduce a framework showing how apparently disparate forms of anosognosia fit together. The central idea is (...) that, to notice a deficit, individuals need to form expectations about normal vision, compare expectations and visual input, and judge any mismatch at the metacognitive level. A failure in any of these three steps may lead to unawareness of visual deficits. (shrink)

Proprioception, a sense of bodily position and movement, is rarely the focus of conscious experience. If we are ordinarily conscious of proprioception, we seem only peripherally so. Thus, evidence that proprioception is present in the periphery of at least some conscious experiences seems to be good evidence that conscious experience is fairly rich. Anosognosia for paralysis is a denial of paralysis of one's limbs, usually in the wake of brain damage from stroke. Because anosognosic patients overlook their paralysis, (...) class='Hi'>anosognosia seems be a counter-example to the claim that proprioception exists in the periphery of conscious experience. However, careful consideration of the data shows that anosognosia makes a poor counterexample to a rich theory of consciousness. Thus, we retain reason to believe that proprioception exists in the periphery of conscious experience, and so to conclude that conscious experience is relatively rich. (shrink)

Patients with right parietal lesions often deny their paralysis , but do they have "tacit" knowledge of their paralysis? I devised three novel tests to explore this. First, the patients were given a choice between a bimanual task vs a unimanual one . They chose the former on 17 of 18 trials and, surprisingly, showed no frustration or learning despite repeated failed attempts. I conclude that they have no tacit knowledge of paralysis . Second, I used a "virtual reality box" (...) to convey the optical illusion to the patient that she was moving her paralyzed left hand up and down to the rhythm of a metronome, and yet she showed no sign of surprise. Third, I irrigated patient BM′s left ear canal with cold water, a procedure that is known to shift that patient′s spatial frame of reference by stimulating the vestibular system. Surprisingly, this allowed her "repressed" memory of paralysis to come to the surface; she said she had been paralyzed continuously for several days. I suggest that the vestibular stimulation produces these remarkable effects by mimicking REM sleep. These patients also emply a whole arsenal of grossly exaggerated Freudian "defense mechanisms" to account for their paralysis. To explain this, I propose that in normal individuals the left hemisphere ordinarily deals with small, local anomalies by trying to impose consistency but, when the anomaly exceeds threshold, an interaction with the right hemisphere forces a "paradigm shift". A failure of this process, in patients with right hemisphere damage, might partially account for anosognosia. Finally, I present a new conceptual framework that may help link several psychological and neurological phenomena such as Freudian defense mechanisms, vestibular stimulation, anosognosia, memory repression, visual illusions, anterograde amnesia, REM sleep, dreaming, and humor. (shrink)

The traditional conception of self-deception takes it for an intrapersonal form of interpersonal deception. However, since the same subject is at the same time deceiver and deceived, this means attributing the agent a pair of contradictory beliefs. In the course of defending a deflationary conception of self-deception, Mele [1997] has challenged traditionalists to present convincing evidence that there are cases of self-deception in which what he calls the dual belief-requirement is satisfied. Levy [2009] has responded to this challenge affirming that (...) there is at least one real cases of self-deception that meets this requirement, namely, that of anosognosia. In this family of conditions, the patient apparently believes that there is nothing wrong with her while, at the same time, providing behavioral cues that indicate that the patient is somehow aware of his disease. If Levy is right, then traditionalism about self-deception could be vindicated, after having been widely abandoned due to its need to postulate exotic mental processes in order to make sense of the attribution of contradictory beliefs. In this paper, I assess whether Levy’s response to Mele’s challenge is successful by analyzing his interpretation of the empirical evidence to which he appeals. Finally, I attack the cogency of the underlying commitments about the nature of folk psychology to which one is required to defer in order to draw from conflicting evidence the attribution of contradictory beliefs. (shrink)

This paper reviews the literature concerning the neural correlates of the self, the relationship between self and memory and the profile of memory impairments in Alzheimer’s disease and explores the relationship between the preservation of the self and anosognosia in this condition. It concludes that a potential explanation for anosognosia in AD is a lack of updating of personal information due to the memory impairments characteristic of this disease. We put forward the hypothesis that anosognosia is due (...) in part to the “petrified self.”. (shrink)

Currently, the number of patients diagnosed with impaired self-awareness of their own deficits after brain injury—anosognosia— is increasing. One reason is a growing understanding of this multifaceted phenomenon. Another is the development and accessibility of alternative measurements that allow more detailed diagnoses. Anosognosia can adversely affect successful rehabilitation, as often patients lack confidence in the need for treatment. Planning such treatment can become a complex process full of ethical dilemmas.To date, there is no systematic way to deal with (...) different aspects of anosognosia rehabilitation planning. This is the first article to present a framework for ethical decision making in establishing rehabilitation plans that are focused on increasing patients’ self-awareness of their own deficits after brain injury. It concentrates especially on addressing the ethical dilemmas that may arise, and describes stepwise procedures that can be applied to distinct theoretical approaches, as well as diagnostic and rehabilitation methods. To show the flexibility of the use of this framework, alternative approaches are discussed. (shrink)

Somatoparaphrenia is a pathology of self characterized by the sense of alienaton from parts of one’s body. It is usually construed as a kind of delusional disorder caused by extensive right hemisphere lesions. Lesions in the temporoparietal junction are common in somatoparaphrenia but deep cortical regions (for example, the posterior insula) and subcortical regions (for example, the basal ganglia) are also sometimes implicated (Valler and Ronschi 2009). Patients are often described as feeling that a limb belongs to another person and (...) thus attribute ownership of the limb and bodily sensation to someone else. There is also some question as to whether or not the higher-order thought (HOT) theory of consciousness can plausibly account for the depersonalization psychopathology of somatoparaphrenia (Liang and Lane 2009, Rosenthal 2010, Lane and Liang 2010). Liang and Lane argue that it cannot. The HOT theory of consciousness says that what makes a mental state a conscious mental state is that it is the target of a HOT to the effect that “I am in mental state M” (Rosenthal 2005, Gennaro 2012). When the HOT is itself is unconscious, the conscious state is still outer-directed. When the HOT is conscious, we have introspection and so the conscious thought is directed at the mental state. In section I, I briefly review the previous exchange between Lane and Liang and David Rosenthal. In section II, I further explore somatoparaphrenia and the nature of delusion while offering a number of additional replies to Lane and Liang. In section III, I examine the central notions of “mental state ownership” and “self-concepts” in an effort to account especially for the depersonalization aspect of somatoparaphrenia against the background of HOT theory. In section IV, I argue that to the extent that somatoparaphrenia casts doubt on the notion that some thoughts are “immune to error through misidentification” (IEM), the most fundamental aspect of IEM is still consistent with HOT theory. Overall, I argue that HOT theory is left unscathed by the pheneomenon of somatoparaphrenia and can even help to explain what happens in these cases. (shrink)

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. (shrink)

Except for a patina of twenty-first century modernity, in the form of logic and language, philosophy is exactly the same now as it ever was; it has made no progress whatsoever. We philosophers wrestle with the exact same problems the Pre-Socratics wrestled with. Even more outrageous than this claim, though, is the blatant denial of its obvious truth by many practicing philosophers. The No-Progress view is explored and argued for here. Its denial is diagnosed as a form of anosognosia, (...) a mental condition where the affected person denies there is any problem. The theories of two eminent philosophers supporting the No-Progress view are also examined. The final section offers an explanation for philosophy 's inability to solve any philosophical problem, ever. The paper closes with some reflections on philosophy 's future. (shrink)

This volume provides, for the first time, multidisciplinary perspectives on the problem of awareness of deficits following brain injury. Such deficits may involve perception, attention, memory, language, or motor functions, and they can seriously disrupt an individual's ability to function. However, some brain-damaged patients are entirely unaware of the existence or severity of their deficits, even when they are easily noticed by others. In addressing these topics, contributors cover the entire range of neuropsychological syndromes in which problems with awareness of (...) deficit are observed: hemiplegia and hemianopia, amnesia, aphasia, traumatic head injury, dementia, and others. On the clinical side, leading researchers delineate the implications of awareness of deficits for rehabilitation and patient management, and the role of defense mechanisms such as denial. Theoretical discussions focus on the importance of awareness disturbances for better understanding such cognitive processes as attention, consciousness, and monitoring. (shrink)

When a person with dementia (PwD) makes a specific request or behaves in a particular way that is inappropriate or dangerous and based on a false understanding of reality, there is a particular technique that caregivers may use to try and manage the situation. The technique is known as ‘diversion’ and it works by affirming the false beliefs and behaviour of a PwD and creating the false impression that their specific request will be fulfilled. It may take the form of (...) an explicit lie or any other communicative response or provision of care that either explicitly or tacitly affirms their false beliefs. It therefore raises the same kind of ethical issues as when lying (or not telling the truth) is done for so called ‘therapeutic’ purposes. The main type of argument used to justify this so called ‘therapeutic lying’ is that it is primarily aimed at benefiting the patient rather than the liar. The same kind of argument can be made for diversion, which is that it is primarily aimed at benefiting the PwD by aiming to ensure their safety and well-being. I argue that insofar as diversion is practiced in this way, it is consistent with the idea of ‘person-centred care’ (PCC) and can be ethically justified on those grounds. Therefore, however, we must be wary of situations where diversion is not practiced in this way, where it is primarily aimed at benefiting caregivers or care providers, and thus inconsistent with PCC. (shrink)

Tim Bayne and Elisabeth Pacherie (2007) propose an integrated model for agentive awareness that incorporates features from both the narrator and the comparator-based accounts found in the literature. Although they think the comparator system is responsible for generating the bulk of agentive experience, they believe the narrator module is responsible for forming agentive judgments and conceptually-laden intentions. Crucially, they also suggest that in some instances the narrator module may “override” the deliverances of the low-level comparator mechanisms. In this paper, I (...) apply Bayne and Pacherie’s integrated model to account for an issue in the psychopathology literature, namely the presence of anosognosia (i.e. ignorance with respect to one’s illness) in anorexia nervosa. In particular, I show that by implementing the integrated model we can solve a problem that arises out of a recent advancement in the empirical literature concerning anorexia’s pathogenesis and persistence. If my proposal is correct, the explanatory power of implementing an integrated model for agentive awareness would bolster Bayne and Pacherie’s account. It may also be of use to researchers seeking to develop a better understanding of anosognosia in anorexia nervosa, which remains a poorly understood feature of the disorder. (shrink)

Disability imagery, whether photographs, posters, or verbal or written discourse, comprises multiple viewpoints or gazes, ranging from the impaired physical body to the disabling social environment. In some instances, photographic image and accompanying text combine to reinforce the notion of persons with disabilities as helpless and needy people. These conceptualizations not only emphasize obvious prejudices and limited thinking about persons with disabilities, but also illustrate the consequences: persons with disabilities tend to assimilate the oppressive images constructed by society. In order (...) to create positive images of, for example, persons with brain injury, epilepsy or hemiplegia, we need to develop a disability consciousness that allows us to re-imagine (dis)ability in ways that value individual identity. In so doing, we raise critical questions about self and other. (shrink)

: Self-consciousness is considered in a framework comprising four dimensions which are theoretically defined and supported by clinical neuropsychological evidence. Self-monitoring is defined as the ability to reflect on one’s own behaviour, with supporting evidence for deficits in this capacity noted in anosognosia syndrome. Self-feeling is defined as the capacity to feel all sensations related to one’s own body, with supporting evidence from deficiencies occurring in alexithymia, psychosomatic states and Cotard’s delusion. Identity refers to the capacity to recognize an (...) object as identical to oneself, based on autobiographic memory; pathological conditions related to this dimension include delusions of identity and the Zelig syndrome. Ownership is the capacity to perceive the status of ones’ own body, and is clinically altered in somatoparaphrenia. All four dimensions are related to specific brain networks. Keywords: Self-Monitoring; Self-Feeling; Identity; Ownership; Neurocognitive Dimensions Le dimensioni neurocognitive dell’autocoscienza Riassunto: L’autocoscienza viene inquadrata in base a quattro dimensioni, determinate in via teorica e supportate da evidenze cliniche di carattere neuropsicologico. L’automonitoraggio è definito quale capacità di riflettere sul proprio comportamento ed è sostenuto da evidenze che derivano da quella sindrome denominata anosognosia. Il sentire il proprio sé è la capacità di avvertire tutte le sensazioni del corpo proprio ; questa dimensione è supportata da evidenze derivanti da condizioni cliniche quali l’alessitimia, le affezioni psicosomatiche e il delirio di Cotard. L’identità si riferisce alla capacità di riconoscere come identico a se stesso un oggetto, fondata sulla memoria autobiografica; le condizioni patologiche legate a questa dimensione sono il delirio di identità e la sindrome di Zelig. Il possesso di sé è la capacità di percepire lo stato del proprio corpo, condizione che risulta alterata nella somatoparafrenia. Tutte queste quattro dimensioni sono collegate a specifici network cerebrali. Parole chiave: Automonitoraggio; Sentimento di sé; Identità; Padronanza di sé; Dimensioni neurocognitive. (shrink)

Hemiparetic stroke in adulthood often results in the grouped movement pattern of the upper extremity flexion synergy thought to arise from an increased reliance on cortico-reticulospinal pathways due to a loss of lateral corticospinal projections. It is well-established that the flexion synergy induces reaching constraints in individuals with adult-onset hemiplegia. The expression of the flexion synergy in individuals with brain injuries onset earlier in the lifespan is currently unknown. An early unilateral brain injury occurring prior to six months post (...) full-term may preserve corticospinal projections which can be used for independent joint control and thus minimizing the expression of the flexion synergy. This study uses kinematics of a ballistic reaching task to evaluate the expression of the flexion synergy in individuals with pediatric-onset hemiplegia (PH) ages six to seventeen years. Fifteen individuals with brain injuries before birth (n = 8) and around full-term (n = 7) and nine age-matched controls with no known neurological impairment completed a set of reaches in an admittance controlled robotic device. Descending drive, and the possible expression of the upper extremity flexion snergy, was modulated by increasing shoulder abduction loading. Individuals with early PH achieved lower peak velocities when reaching with the paretic arm compared to controls however no differences in reaching distance were found between groups. Relative maintenance in reaching seen in individuals with early brain injuries highlights minimal expression of the flexion synergy. We interpret this conservation of independent control of the paretic shoulder and elbow as the use of more direct corticospinal projections instead of indirect cortico-reticulospinal pathways used in individuals with adult-onset hemiplegia. (shrink)

Event-related desynchronization, as a proxy for mirror neuron activity, has been used as a neurophysiological marker for motor execution after mirror visual feedback. Using EEG, this study investigated ERD upon the immediate effects of single-session MVF in unimanual arm movements compared with the ERD effects occurring without a mirror, in two groups: stroke patients with left hemiplegia and their healthy counterparts. During EEG recordings, each group performed one session of mirror therapy training in three task conditions: with a mirror, (...) with no mirror, and with a covered mirror. An asymmetry index was calculated from the subtraction of the event-related spectrum perturbations between the C3 and C4 electrodes located over the sensorimotor cortices contralateral and ipsilateral to the moved arm. Results of the effect of task versus group in contralateral and ipsilateral motor areas showed that there was a significant effect of task condition at the contralateral motor area in the high beta band at C3. High beta ERD showed that the suppression was greater over the contralateral hemisphere than it was over the ipsilateral hemisphere in both study groups. The magnitude of low beta ERD in patients with stroke was more suppressed in contralesional C3 under the no mirror compared to that of the covered mirror and similarly more suppressed in ipsilesional C4 ERD under the no mirror compared to that of the mirror condition. The correlation analysis revealed that the magnitude of ERSP power correlated significantly with arm severity in the low and high beta bands in patients with stroke, and a higher asymmetry index in the low beta band was associated with higher arm functioning under the no-mirror condition. There was a shift in sensorimotor ERD toward the contralateral hemisphere as induced by MVF accompanying unimanual movement in both stroke patients and healthy controls. The use of ERD in the low beta band as a neurophysiological marker to indicate the relationships between the amount of MVF-induced ERD attenuation and motor severity, and the outcome indicator for improving stroke patients’ neuroplasticity in clinical trials using MVF are warranted to be explored in the future. (shrink)

A referral was made to our Cardiac Transplant Program for a patient who was in the New Jersey Prison System. The Medical Director of the New Jersey Department of Corrections called regarding a 39-year-old inmate who was being treated in a New Jersey hospital that has a unit for prisoners from a nearby cor- rectional facility. The referring physician described the patient to our Medical Director of heart transplantation as a “murderer” who had been incarcerated since 1987 and sentenced to (...) prison for 30 years without eligibility for parole before completion of his 30-year sentence. The patient was being treated in the CCU of the facility and according to preliminary studies, was suffering from a possible dilated cardiomyopathy. There was evidence of a prior cerebrovascular accident (etiology unknown) with a dense hemiplegia of the left side. The patient was alert but unable to care for himself. There were a number of specific tests necessary to evaluate the patient's candidacy for heart transplantation before actually placing him-on a waiting list. However, the transplant director was uncertain about having the patient brought to our facility for further testing and called some members of the Transplant Selection Committee team to discuss the case. (shrink)

Mulder and colleagues [Mulder, T., Hochstenbach, J., Dijkstra, P. U., Geertzen, J. H. B. . Born to adapt, but not in your dreams. Consciousness and Cognition, 17, 1266–1271.] report that a majority of amputees continue to experience a normally-limbed body during their night dreams. They interprete this observation as a failure of the body schema to adapt to the new body shape. The present note does not question this interpretation, but points to the already existing literature on the phenomenology of (...) the phantom limb in dreams. A summary of published investigations is complemented by a note on phantom phenomena in the dreams of paraplegic patients and persons born without a limb. Integration of the available data allows the recommendation for prospective studies to consider dream content in more detail. For instance, “adaptation” to the loss of a limb can also manifest itself by seeing oneself surrounded by amputees. Such projective types of anosognosia in nocturnal dreams should also be experimentally induced in normally-limbed individuals, and some relevant techniques are mentioned. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Response to the CommentariesSean A. SpenceIn “Free Will in the Light of Neuropsychiatry,” I have attempted to present an argument from the perspective of materialist neuroscience, pushing the latter to its logical conclusion: that if the human nervous system is consistent in its properties, then the only place for “free will” is in the non-conscious processes which underpin conscious awareness. This argument I have based on two supports: the (...) “spatial” and the “temporal” (Spence, 1995).I have contended that the sense of freedom may be lost from certain actions, thereby implying that “freedom” is a sensory process distinct from action. This might be conceptualized as having a distinct functional distribution within the nervous system (a spatial distinction). I have also argued that conscious awareness of events occurs at a finite delay, the period of “neuronal adequacy,” after those events themselves. The point here is that neurochemical events giving rise to phenomenology are likely to require a period of time (no matter how short) for their genesis. The process is “on line” before we perceive it (a temporal distinction). Thus the “freedom to act,” a motor process, is necessarily non-conscious at the point of initiation.I am grateful to Frith, Libet and Stephens for their comments. In the most part our disagreements are likely to be those of emphasis, perhaps compounded by my uses of the term “free will.”I have no major disagreement with Frith’s comments. I would, however, emphasize that it is likely that the Bereitschaftspotential, or readiness potential, does tell us something regarding intended actions. It is, for example, absent prior to the involuntary movements seen in Tourette’s syndrome (Obeso et al. 1982), and reduced in akinetic patients with Parkinson’s disease (Dick et al. 1989) or medial frontal lobe lesions (Deecke et al. 1987). The latter groups have difficulty initiating intended, internally generated, actions.With regard to the suspicion of dualism in my diagrams, the point is well taken, but I am attempting to describe a functional distinction, the precise coordinates of which remain obscure. It may well be that “consciousness” occupies no fixed location but is an activity temporarily co-extant with that association cortex (or cortices) subserving the sensory modality (or modalities) experienced phenomenologically (see Bottini et al. 1995).I have based much of my “temporal” argument on Libet’s work, and I am grateful for his response. Nevertheless, I am still of the opinion that there is a central inconsistency with his argument that conscious control exerts a veto on acts which is somehow free of material constraints. [Indeed he states that he has “no quarrel with the view that even a fully voluntary act is initiated unconsciously (non-consciously)”.] Whereas I can [End Page 99] not prove that this power of veto does not evade neurochemical processes, or that it somehow acts instantaneously and independently, with no origin in unconscious processing, I can say that I have restricted myself to arguing within a materialist perspective, with the aim of “pushing it” to its extreme. The free will which Libet retains in consciousness is one which is unique, and unconstrained by materialism. It is dualism in disguise!Stephens implies that there is a non-argument regarding consciousness acting as an initiator of events. The suggestion is that no one would argue this. Yet this is Libet’s argument. It cannot be disproved, but it is clearly (internally) inconsistent with Libet’s own impressive body of work.As for the role of consciousness in action, I have, I think, invoked a position similar to that adopted by Stephens; that consciousness is more a sensory state, allowing awareness of actions, and their consequences, and perhaps thereby facilitating the function of non-conscious initiators. It is clearly necessary for the performance of the “higher” acts which we equate with human nature, but it is not sufficient. (Indeed many of the most creative insights have “emerged” into consciousness [see Boden, 1992].) The man with a paralyzed arm may wish for his arm to move but to no avail. Over time function may slowly reappear. But if his lesion is such that he is unaware of his impairment (anosognosia), then his prognosis may... (shrink)

This book brings together perspectives on predictive processing and expected experience. It features contributions from an interdisciplinary group of authors specializing in philosophy, psychology, cognitive science, and neuroscience. Predictive processing, or predictive coding, is the theory that the brain constantly minimizes the error of its predictions based on the sensory input it receives from the world. This process of prediction error minimization has numerous implications for different forms of conscious and perceptual experience. The chapters in this volume explore these implications (...) and various phenomenon related to them. The contributors tackle issues related to precision estimation, sensory prediction, probabilistic perception, and attention, as well as the role predictive processing plays in emotion, action, psychotic experience, anosognosia, and gut complex. Expected Experiences will be of interest to scholars and advanced students in philosophy, psychology, and cognitive science working on issues related to predictive processing and coding. (shrink)

This article explores a literary tradition situated at the intersection of scientific reports, memoirs, and creative writing, termed “clinical narrative.” This genre offers a profound approach to the painful aspects of conscious experience, particularly the phenomenological states associated with mental illness and brain disease, seen as unsettling landscapes of phenomenal experience. Through case studies providing multifaceted viewpoints – first-person, second-person, and third-person perspectives – we argue that clinical narratives are valuable resources for a transepistemic study of consciousness. By examining clinical (...) conundrums such as somatic and nihilistic delusions, and anosognosia, we highlight the importance of detailed phenomenological, hermeneutic, and narrative accounts while acknowledging the significance of subpersonal, mechanistic models from cognitive and affective neuroscience. The tradition embodies the tension between the diverse perspectives in the field of mental health, including stories that directly challenge the medical discourse. However, the narrative arts can act as mediators or even peacemakers, by fostering an understanding between the opposing views. Stories are open to multiple interpretations, preserving the diversity of discourses on human meaning and avoiding the imposition of monolithic versions of our humanness. (shrink)

Facial fat grafting techniques often offer impressive surgical results. However, fatal complications, such as irreversible cerebral ischemia, blindness, and hemiplegia are associated with them. We have presented a case report of a patient who presented with a massive cerebral infarction, a serious complication of facial autologous fat injection. The patient was a 28-year-old female who experienced motor dysfunction of the left extremities, which was accompanied with loss of consciousness immediately following fat grafting for facial augmentation. Imaging studies suggested that (...) the patient had a large cerebral infarction on the right frontal, temporal, and parietal lobes due to complete occlusion of her right external carotid artery. Emergency decompressive craniectomy was completed in addition to multiple follow-up medical treatments. The patient recovered after 4 months with reduced motor function in her left upper extremity. This report further summarizes published cases of massive cerebral ischemia after facial injection of autologous fat, as well as lists high-risk facial areas and critical warnings. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it often (...) comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

Gil R, Arroyo-Anllo EM, Ingrand P, Gil M, Neau JP, Ornon C, Bonnaud V. Self-consciousness and Alzheimer’s disease. Acta Neurol Scand 2001: 104: 296–300. # Munksgaard 2001. Objectives – To propose a neuropsychological study of the various aspects of self-consciousness (SC) in Alzheimer’s disease. Methods – Forty-five patients with probable mild or moderate AD were included in the study. Severity of their dementia was assessed by the Mini Mental State (MMS). Fourteen questions were prepared to evaluate SC. Results – No (...) significant correlations were found between SC score and educational level, age, and duration of disease. A significant correlation was found between SC score and the severity of dementia, whereas frontal disturbances were just short of the significance threshold. The various aspects of SC were not impaired to the same degree. The most disturbed ones were awareness of cognitive deficiencies, moral judgements and prospective memory. The least disturbed aspects were awareness of identity and of mental representation of the body. Items relating to anosognosia and moral judgements were significantly correlated with the MMS score, whereas affective state, body representation disorders, prospective memory, and capacities for introspection were not related to the severity of the dementia. Consciousness of identity was sound, regardless of MMS score. Conclusions – AD clearly induces an heterogeneous impairment of SC. SC requires a convergence of many neural networks. In AD, neuronal alterations involve many cortical areas and information sent to the associative frontal cortex from memory, language and visuospatial areas is lacking or disturbed. Thus, the sequential order of successive stimuli cannot be maintained by the heteromodal associative cortex (dorsal convexity of the prefrontal cortex), and the supramodal associative cortex (located rostrally in the frontal lobes) is unable to provide reliable monitoring and assessment of simultaneous neural cognitive networks carrying insufficient and inadequate input. The core deficiency in AD patients might be impaired SC equated with the disability to maintain sequential and simultaneous ‘‘attention to life’’. The Self-Consciousness Questionnaire, a clinical scale providing multidimensional measurement, indicates that different aspects of consciousness are not correlated with overall cognitive deficiency as determined by the MMSE. (shrink)

Recent evaluation of the practice of euthanasia and related medical decisions at the end of life in the Netherlands has shown a slight decrease in the frequency of physician-assisted death since the enactment of the Euthanasia Law in 2002. This paper focuses on the absence of euthanasia cases concerning patients with dementia and a written advance euthanasia directive, despite the fact that the only real innovation of the Euthanasia Law consisted precisely in allowing physicians to act upon such directives. The (...) author discusses two principal reasons for this absence. One relates to the uncertainty about whether patients with advanced dementia truly experience the suffering they formerly feared. There is reason to assume that they don’t, as a consequence of psychological adaptation and progressive unawareness (anosognosia). The second, more fundamental reason touches upon the ethical relevance of shared understanding and reciprocity. The author argues that, next to autonomy and mercifulness, “reciprocity” is a condition sine qua non for euthanasia. The absence thereof in advanced dementia renders euthanasia morally inconceivable, even if there are signs of suffering and notwithstanding the presence of an advance euthanasia directive. This does not mean, however, that advance euthanasia directives of patients with dementia are worthless. They might very well have a role in the earlier stages of certain subtypes of the disease. To illustrate this point the author presents a case in which the advance directive helped to create a window of opportunity for reciprocity and shared decision-making. (shrink)

While a number of empirical studies have appeared on impaired self-awareness (ISA) after traumatic brain injury (TBI) over the last 20 years, the relative role of denial (as a psychological method of coping) has typically not been addressed in these studies. We propose that this failure has limited our understanding of how ISA and denial differentially affect efforts to rehabilitate persons with TBI. In this selective review paper, we summarize early findings in the field and integrate those findings with more (...) recent observations (i.e., 1999–2019). We believe that this synthesis of information and expert clinical opinion will inform future research on ISA and denial as well as approaches to rehabilitation for persons with TBI. (shrink)

This article advocates for a hermeneutic model for children-AI (age group 7–11 years) interactions in which the desirable purpose of children’s interaction with artificial intelligence (AI) systems is children's growth. The article perceives AI systems with machine-learning components as having a recursive element when interacting with children. They can learn from an encounter with children and incorporate data from interaction, not only from prior programming. Given the purpose of growth and this recursive element of AI, the article argues for distinguishing (...) the interpretation of bias within the artificial intelligence (AI) ethics and responsible AI discourse. Interpreting bias as a preference and distinguishing between positive (pro-diversity) and negative (discriminative) bias is needed as this would serve children's healthy psychological and moral development. The human-centric AI discourse advocates for an alignment of capacities of humans and capabilities of machines by a focus both on the purpose of humans and on the purpose of machines for humans. The emphasis on mitigating negative biases through data protection, AI law, and certain value-sensitive design frameworks demonstrates that the purpose of the machine for humans is prioritized over the purpose of humans. These top–down frameworks often narrow down the purpose of machines to do-no-harm and they miss accounting for the bottom-up views and developmental needs of children. Therefore, applying a growth model for children-AI interactions that incorporates learning from negative AI-mediated biases and amplifying positive ones would positively benefit children’s development and children-centric AI innovation. Consequently, the article explores:What challenges arise from mitigating negative biases and amplifying positive biases in children-AI interactions and how can a growth model address these?To answer this, the article recommends applying a growth model in open AI co-creational spaces with and for children. In such spaces human–machine and human–human value alignment methods can be collectively applied in such a manner that children can (1) become sensitized toward the effects of AI-mediated negative biases on themselves and others; (2) enable children to appropriate and imbue top-down values of diversity, and non-discrimination with their meanings; (3) enforce children’s right to identity and non-discrimination; (4) guide children in developing an inclusive mindset; (5) inform top-down normative AI frameworks by children’s bottom-up views; (6) contribute to design criteria for children-centric AI. Applying such methods under a growth model in AI co-creational spaces with children could yield an inclusive co-evolution between responsible young humans in the loop and children-centric AI systems. (shrink)