Tuesday, 16 September 2014

Another Perspective on Anosognosia

Sahba Besharati
I am currently in the 3rd year of my PhD undergoing a split-site collaboration project with the University of Cape Town and University College London. This post will focus on a recent publication featured in Neuropsychological Rehabilitation with my supervisor, Katerina Fotopoulou, and our collaborator in Italy, Valentina Moro, on a prototypical form of unawareness called anosognosia for hemiplegia (AHP).

Neurological disturbances in awareness can offer an important avenue to explore the construction of the bodily self. AHP is one such example of a disorder of self-awareness, where patients have a lack of recognition or awareness of their motor paralysis following a stroke. AHP can have various clinical presentations, ranging from blatant denial of limb paralysis and associated delusional beliefs to emotional indifference of one’s motor disabilities.

Although AHP is often transient (sometimes recovering within days or weeks), motor unawareness can significantly obstruct rehabilitation efforts. For example, patients often refuse treatment or do not engage in therapy, have longer hospital stays, and are often less likely to return to independent living. Unfortunately there is currently no failsafe treatment available. However, in a recent study, Dr. Fotopoulou and colleagues showed that self-observation using video replay led to the permanent and total recovery of motor awareness in an acute patient. This is a simple, psychophysical intervention used at the bedside, where AHP patients watch a video replay of themselves falsely claiming that they can move their paralysed arm despite blatant evidence to the contrary.

Our current study tested the feasibility, effectiveness and optimisation of this video intervention with acute and chronic patients. We also adjusted the original intervention protocol by having multiple sessions of “video therapy”, and showing both “self referent” (the patient themselves in the video who is unaware they cannot move) and “other referent” (another paralysed patient who is aware they cannot move) video clips. In all cases rapport building and providing emotional support was an integral part of the intervention. In both acute and chronic patients, video replay had an immediate effect on motor unawareness and acted as an initial trigger to regaining awareness of motor paralysis. However, the study also shows that video replay is not always a stand-alone intervention, and should be embedded into wider, and perhaps individualised, rehabilitation programs. Nevertheless, video replay offers a simple, non-invasive and cost-effective intervention strategy that can be easily administered at the bedside, within a safe, therapeutic environment.

Such bi-directional research is not only of clinical significance, but also offers important theoretical contributions on the role of perspective taking in unawareness syndromes. Video feedback provides visual “third-person” (from the outside) and “off-line” (a time different to the one at which the patient initiated the movement) feedback that might help update their beliefs and facilitate first-person motor awareness. These results suggest that there is a potential disassociation between a first-person person (embodied) and third-person (disembodied) perspective on the body. 

1 comment:

  1. That's freakin' amazing. That seems an analog to Anton's syndrome, where people wont accept they are blind. Of course your treatment wont work in such a case because they are blind and cannot see the treatment!

    But it's freakin' amazing because what is different about watching a video of themselves? Does some denial node in the brain click on when they are confronted, but fails to click on with watching the video? Forgive some evo-psyche hypothesis, but it'd make sense evolution wise to hide incapacity so as not to be outsted from the tribe (OR to avoid being targeted by preditors seeking the weak). Perhaps some reflex like that, that is not only for fooling others but fools the very brain the reflex comes from, is at play?

    It's really amazing to see an analog of Anton's syndrome and even further, that it has a treatment (that an Anton's sydrom patient cannot use...though what if you recorded them speaking and played it back latter?)

    Excuse my amazement! :)

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