09.10.2016 1 Disorders of Bodily Self-Consciousness Roberta Ronchi, PhD Laboratory of Cognitive Neuroscience Center for Neuroprosthetics Ecole Polytechnique Fédérale de Lausanne BODILY SELF-CONSCIOUSNESS: the self within the limits of the body Sense of unity of the self with the body is guaranteed by the integration of multiple sensory sources of information, i.e. exteroceptive and interoceptive signals. Self-identification (what belongs to my body) and self-location (where my body is located in the space) are crucial elements of self-consciousness. (Manipulation and) Pathological conditions: alteration of self-consciousness. Neuroscience of the Self (Blanke and Metzinger, 2009; Blanke, 2012; Blanke et al., 2015)
Transcript
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Disorders of Bodily Self-Consciousness
Roberta Ronchi, PhD
Laboratory of Cognitive NeuroscienceCenter for Neuroprosthetics
Ecole Polytechnique Fédérale de Lausanne
BODILY SELF-CONSCIOUSNESS: the self within the limits of the body
Sense of unity of the self with the body is guaranteed by the integration of multiple sensory sources of information, i.e. exteroceptive and interoceptive signals.
Self-identification (what belongs to my body) and self-location(where my body is located in the space) are crucial elements of self-consciousness.
(Manipulation and) Pathological conditions: alteration of self-consciousness .
Neuroscience of the Self
(Blanke and Metzinger, 2009; Blanke, 2012; Blanke et al., 2015)
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Summary
Inattention and Disownership• Somatoparaphrenia
(SP)• Asomatoagnosia
• Pathological embodiment (E+)
• Personal Neglect
Own body illusions• Out-of-Body
experience (OBE)• Autoscopic
hallucinations
• Heautoscopy• Feeling of a
presence (FoP)
“Un homme examiné quelques heures après une attaque d’apoplexie, présentait une paralysie complète du bras et de la jambe gauches. […]
Il ne reconnaissait pas sa main gauche , même placée dans son champ visuel; il croyait alors que c’était la main du médecin . Les autres facultés psychiques n’étaient pas altérées.”
(Kramer, 1915)
Définition
• Étymologie: – παρα + φρεν, φρενοs: opposition à l’esprit– σωµα, σωµατοs: corps
« Illusions ou distorsions concernant la perception de
et affabulations ou délires du sujet du coté des membres atteints »
(Gerstmann, 1942)
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• Conviction délirante à propos du coté du corps controlatéral à la lésion (ex: négation de la possession d’un membre)
• Rare symptôme “productif” (présence d’un comportement vs absence de réponses demandées) suivant (surtout) un accident vasculaire cérébral
Délire
Somatoparaphrénie (1893-2008)
• 56 patients
- R. Ronchi and G. Vallar, “Somatoparaphrénie après l ésion droite”, Revue de Neuropsychologie (2010), 2 ( 3), 225-230.- G. Vallar and R. Ronchi, “Somatoparaphrenia: a body delusion. A review of the neuropsychological liter ature”, Experimental Brain Research (2009), 192 (3), 533-55 1.
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Somatoparaphrénie (1893-2008)
Principale manifestation
Sensation plus ou moins définie de non-appartenance des membres controlatéraux à la lésion; fréquente (~50%) attribution de la possession à une autre personne (médecin, membre de la famille…)
Prévalence distale de la somatoparaphrénie
• Mainfréquemment
impliquée
• Bras
• Coté contralésionnel
La patiente niait tenacement que la main gauche lui appartenait. Elle insistait que la main n’était pas la sienne, qu’elle l’avait trouvée dans sa chambre et elle l’avait cousue. […] Quand on lui a demandé où se trouvait sa main, elle insistait qu’elle l’avait perdue.[…] Si confrontée avec des évidences (« c’est attachée à votre bras » ), elle admettait que nos raisons semblaient logiques, mais le fait restait que la main ne lui appartenait pas.
(Wortis et Dattner, 1942)
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• Main
• Bras
• Coté
contralésionnel
Elle insistait que son bras gauche n’était pas le sien mais qu’il appartenait à sa mère. (Bisiach et al., 1991)
Très souvent le patient niait l’appartenance de ses bras et jambe gauches. […] Il soutenait que ses membres avaient été amputés en 1964. (Halligan et al., 1993)
Autres manifestations
• Parties du corps “étranges”(Anton, 1893 – Roth, 1949)
• Main séparée du reste du corps(Potzl, 1935)
• Coté gauche différent du coté droit et perçu comme maléfique, contrôlé par des agents extérieurs qui amènent le patient à faire des actions mauvaises(Nightingale, 1982)
« J’ai mordu ma sœur, pas moi-même! »
Association avec la Misoplégie
La patiente signalait qu’elle avait gentiment demandé à sa sœur de s’éloigner parce qu’il n’y avait pas assez d’espace pour deux personnes dans le lit. Comme sa sœur transgressait son désir, elle était en colère. Enfin à plusieurs reprises elle mordait le bras de sa sœur (en fait, son bras ).
(Brugger, cas non publié)
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Déficits neurologiques
• La majorité des patients présentent un sévère syndrome sensori-moteur
MAIScertains patients ne montrent pas
Hémiplégie, Hémianesthésie, Hémianopsie
Le délire somatoparaphrénique persiste quand la partie du corps affectée par le délire est placée devant le patient, dans son hémichamp visuel
intact ou en vision centrale.
Déficits neurologiques
certains patients ne montrent pas Hémiplégie, Hémianesthésie, Hémianopsie
DISSOCIATION SP-DEFICIT SENSORIEL:
- Main G dans l’espace D: rémission du déficit somato-sensoriel
(Aglioti et al., 1996; Moro et al., 2004)
Déficits neurologiques
certains patients ne montrent pas Hémiplégie, Hémianesthésie, Hémianopsie
DISSOCIATION SP-DEFICIT SENSORIEL:
- Manipulation cognitive: présence de sensibilité tactile quand on touche « la main de la nièce »(Bottini et al., 2002)
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PROPRIOCEPTION• 54/56 patients: absence du sens de la position
spatiale des membres SP
• 2/56 patients (Nightingale, 1982; Starkstein et al., 1990): délire SP différent de la non-appartenance
FORTE ASSOCIATION ENTRE LA CONNAISSANCE DE LA POSITION ET LE SENS DE POSSESION
DES PARTIES DU CORPS: DISTINCTION ENTRE LES MEMBRES PROPRES ET DES AUTRES
Neuropsychological syndrome in which patients fail to orient to, explore, report events occurring in the portion of space contralateral to the side of the hemispheric lesion (contralesional), usually the L space.
(Vallar, 1998; Bisiach and Vallar, 2000; Vallar and Bolognini, 2014)
Clinical Manifestations:
- Head and eyes deviated towards
the ipsilesional side
- Objects/People in the
contralesional (neglect) hemi-space
are ignored
- Food left on the contralesional part
of the space
- If walking possible: patients hit on
the wall
….
NEAR SPACE
FAR SPACE
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Symptômes spatiaux et SP
• Associée à la Négligence Spatiale Unilatérale (54/56P):– Garcin et al. (1938): délire SP différent de la
non-appartenance– Cereda et al. (2002): SP transitoire
ATTENTION: la négligence spatiale ne constitue pas une condition suffisante en soi pour la survenue d’une
somatoparaphrénie, puisque de nombreux patients héminégligents ne présentent pas ce
rare symptôme
Stimulation Vestibulaire et NSU
SVC froide à l’oreille gauche
AVANT SVC APRES SVC
• Rémission temporaire de la SP après stimulation vestibulaire calorique:
Lésion HD: Bisiach et al., 1991; Rode et al., 1992; Salvato et al., 2015Lésion HG: Schiff and Pulver, 1999
Distinction floue entre objets corporels (propre partie du corps) et extracorporels
(partie du corps des autres personnes, objets non-corporels…)
Stimulation Vestibulaire et SP
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Between 2009 and 2016…
• Cogliano et al., 2012 (Cortex) : two chronic patients with SP (1 RBD and 1 LBD), with spatial neglect. LBD with proprioceptive deficit
• Pugnaghi et al., 2012 (Neurol Sci) : one RBD patient with SP and severe spatial neglect
• Salvato et al., 2015 (Neurocase) : one chronic RBD patient with SP: signs worsened when the patient was interviewed from the left compared to the right bedside
• Perren et al., 2015 (EBR) : “crossed somatoparaphrenia” = patients with LBD and R spatial neglect, SP involving the L body
• ....
• 5 RBD patients with SP in the acute or subacute phase
Anticipatory response to threatening stimuli is strictly dependent on the sense of ownership for the threatened body part:
DISRUPTED BODY REPRESENTATION
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Lesion correlates
• Vallar and Ronchi (2009): Review– Many patients had extensive fronto-temporo-parietal
lesions; the relevant neural circuitry, may also include deep cortical regions
• Baier and Karnath (2008): – RBD patients with different pathological attitude towards
the contralesional limbs. The right posterior insulaseems to be a crucial structure involved in the genesis of the sense of limb ownership
Lesion studies about SP
• Gandola et al. (2012) Cortex SP+ (11) vs. SP- (11)
Remission of Somatoparaphrenia:JJ and MPS
CASE REPORTBolognini et al., Neurolgy Clinical Practice 2014
P2: MPS- Right-handed male patient, 72
years-old, 7 years of education- Neoplastic lesion (meningioma) in the right parasellar region
- Neurological examination: L hemiplegia, L hemianesthesia, L hemianopia
- Neuropsychological examination: USN extrapersonal and personal
P1: JJ- Right-handed female patient, 97
years-old, 17 years of education- CVA right hemisphere: fronto-
parieto-temporal, insula, basal ganglia
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Ownership and Disownership
A fake arm feels like my arm and is associated with abnormal arm localization
(Botvinick and Cohen, 1998; Armel & Ramachandran, 2003)
Subjective responses« The fake hand feels like my real hand »
Arm position recalibration
Ownership and Disownership
THE RUBBER HAND ILLUSION (RHI)
Can somatoparaphrenic patients experience the RHI?
Can somatoparaphrenic patients restore the ownership
of their L hand through multisensory stimulation?
Bolognini et al., Neurolgy Clinical Practice 2014
Rubber Hand Illusion (1): right hand and right rubber hand
P1, P2, 12 control subjects
T-tests single value vs. control group (Crawford and Garthwaite, 2002)all p > 0.07, ns
Bolognini et al., Neurolgy Clinical Practice 2014
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Rubber Hand Illusion (2): right hand and left (fake) hand
P1, P2, 12 control subjects
Whose is this hand?
Right Left
Mine MineP1, P2
Before RHI
6 trials
Right Left
Mine Other’sP1, P2
After RHI
Right Left
Mine Other’sP1
After 10minutes RHI
Mine MineP2
Long-lasting effect: up to 24h!
No change ofneurological (motor, sensory, visual-field) deficits
as well as spatial neglect
Bolognini et al., Neurolgy Clinical Practice 2014
Own-body illusions, hallucinations, and delusions
Illusory reduplication of the patient’s own body are complex illusory own-body perceptions during which people “perceive” a second own body and/or a second self (i.e., a double) in the environment
Doubles may be seen, felt, and heard, and they may even concern the inner organs of the patient
Several forms of doubles have been described in the literature, and are usually classified under the label of “autoscopicphenomena”. The most frequent illusory own body reduplication is the feeling of a presence (sensori-motor double)
Out-of-body experience
OBE characterized by three elements: 1) the feeling of being outside
one’s physical body (i.e., disembodiment);
2) the perceived location of the self at a distanced and elevated visuo-spatial perspective;
3) the experience of seeing of one’s own body from this elevated perspective
(Bünning and Blanke, 2005)
“I was floating in the very air, rigidly horizontal, a few feet above the bed […] I was moving toward the ceiling, horizontal and powerless […] I managed to turn around and there […] was another ‘me’ lying quietly upon the bed” (Muldoon & Carrington, 1929)
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Out-of-body experience OBEs seem associated with damage to the right and left TPJ
(Blanke et al., 2004; Maillard et al., 2004)
(Blanke et al., 2002)(De Ridder et al., 2007)(Ionta et al., 2011)
But recent data proposed that OBEs during epileptic seizures are not linked to one specific region � group study where localization of seizures in patients with and without OBEs was comparable (Greyson et al., 2014)
OBEs and vestibular sensations: feelings of elevation, floating, 180°inversion, change in visuo-spatial perspective in extrapersonal space� otholithic dysfunctions are one important cause of OBEs? (Lopez et al., 2008; Blanke, 2012)
TPJ linked to OBEs and to multisensory integration (i.e., Bremmer et al., 2001; Calvert, 2001)
OBEs possibly caused by disturbed integration of multiple bodily signals (e.g., somatosensory, visual) in the peri-personal space and inputs disintegration (e.g., visual and vestibular signals) in the external space (Blanke, 2012)
Out-of-body experience
Heautoscopy
Patients experience to see a double of their body in the extrapersonalspace: it may be difficult to decide whether the center of conscious experience (i.e., the self) is localized within the physical body or in the “other” body
[The patient] has the immediate impression as if she were seeing herself from behind herself. She felt as if she were ‘‘standing at the foot of my bed and looking down at myself.’’ Yet, [. . .], the patient also has the impression to ‘‘see’’ from her physical [or bodily] visuo-spatial perspective, which looked at the wall immediately in front of her. Asked at which of these two positions she thinks herself to be, she answered that “I am at both positions at the same time” (Blanke et al., 2004)
Patients often experience the so-called bilocation (i.e. the feeling of existing at two places at the same time)
(Blanke and Mohr, 2005; Blanke and Castillo, 2007)
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Heautoscopy
N= 9 patients with epilepsy (8) or migraine (1)
(Heydrich and Blanke, 2013)
Heautoscopy
(adapted from Blanke et al., 2008)
Involvement of the insula in the genesis of heautoscopy:- Patients with heautoscopy often experience
altered emotional states and visceroceptivesensations
- Insula linked to interoceptive processing and encoding of emotionally relevant events for self and other
HP: disintegration of exteroceptive bodily signals with emotional and/or visceral ones. This disintegration results in abnormal self-identification and amplified emotional affinity for the autoscopic body
Feeling of a Presence
Illusion that somebody is close by, although nobody is around
A 55 year-old right handed woman reported several times a day the brief sensation of having “a shadow” in her right peri-personal space. She described that “the shadow is always in front of me, about 50 cm to the right. I feel that it is very familiar to me, and I kind of know that it is a male shadow”. She did not see the shadow yet she could “feel” it, although she knew that there is nothing there. (Brugger et al., 1996)
(Brugger et al., 1996; Critchley, 1950, 1955; Lhermitte, 1939; Fenelon et al., 2011)
Psychiatric and neurological patients (epilepsy, stroke, Parkinson’s disease)
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Feeling of a PresenceBrain correlates
FoP (N= 12) Control patients (N= 12)
[ 3 patients ; 4 patients ; 5 patients ]
FoP is caused by damage to:• temporo-parietal cortex• fronto-parietal cortex • insular cortex (Blanke et al., 2014)
Feeling of a PresenceRobot-Controlled Bodily Illusions
(Blakemore et al., 2002)
(Blanke et al., 2014)
Feeling of a PresenceRobot-Controlled Bodily Illusions
Questionnaire
(Blanke et al., 2014)
The robotic data showed that sensorimotor conflicts are sufficient to induce the
FoP (even if more weak than in neurological
patients)
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The link between the self and the body is guaranteed by the integration of signals coming from the inside and the outside of the body
Experimentally induced manipulations of such signals (e.g., visuo-tactile, sensory-motor, cardio-visual conflicts) temporarily alter basic features of bodily self-consciousness
Pathological conditions can strongly alter bodily self-consciousness, ranging from “negative” manifestations (missed body) to “positive” manifestations (the feeling of a double)
Self-identification, self-location and perspectiveApply technology to restore bodily disorders
