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WHAT IS ASOMATOGNOSIA?

Asomatognosia is generally known as a disorder of body awareness caused by neurological damage (Dieguez, Staub, and Bogousslavsky, 2007 & Pinel, 2006). The deficit in body awareness can take the form of forgetting, ignoring, denying, disowning, or misperceiving the body (entirely or partially) (Arzy, Overney, Landis, and Blanke, 2006 & Dieguez et al., 2007). The duration of symptoms for asomatognosia can vary in a span of minutes, hours, or months. There are two major ways of viewing asomatognosia as one specific disorder, or as a general definition under which many different disorders can be categorized into. To add to the confusion, many of the disorders have multiple names that are used within the literature. When asomatognosia is viewed generally, Dieguez et al. (2007) explains that it can further be categorized as being productive, where something appears (i.e. hand is seen as rotting) or defective, where something disappears or is missing (i.e. hand is no longer viewed as being attached to the body). Patients with asomatognosia can shift between having productive or defective symptoms very rapidly. From these two categories, the disorders falling under asomatognosia can be additionally specified according to the patients attitude towards their own body. There are three different types of attitudes including indifferent, delusional, or critical (Dieguez et al., 2007). An indifferent attitude is defined as when the client seems to act as if nothing has changed or has gone wrong while a delusional attitude is when the client rationalizes in order to explain the change. Finally, a critical attitude is when the client has awareness of the change or has strange feelings concerning their body and tries to explain them, usually by making comparisons (i.e. it feels like my hand is just a dead weight). Dieguez et al. (2007) describe several disorders that they would categorize under asomatognosia (see Figure 1). This paper will only focus on a few of these in greater detail including hemiasomatognosia, somatophrenia, and misoplegia. Hemiasomatognosia occurs when lesions are located in the

right gyrus supramarginalis and in surrounding underlying structures (Dieguez et al., 2007). Patients with hemiasomatognosia act as if half of their body no longer exists. In some cases,

patients will even deny that half of their body ever existed. If these patients are given proof of the existence of the other half of their body, they tend to have either of the following reactions: acceptance or delusional explanation. If they respond to evidence of their body with delusions, they are usually diagnosed with somatophrenia. Somatophrenia is very similar to hemiasomatognosia in the fact that patients will deny that parts of their body belong to them. They tend to claim that the body part, generally the contralesional hand or arm, is missing or has been stolen (Dieguez et al., 2007). When asked whose arm is by them, they may respond that the arm belongs to someone else (i.e. a relative alive or dead and/or medical staff), that it is an animal (i.e. snake), or its part of a rotting corpse. There have also been cases where patients describe that their arm is no longer theirs because it has been possessed by a relative, an unknown ghost, or even the devil. Generally, even after patients with somatophrenia are shown that their affected limbs are attached to the rest of their body they do not accept the evidence. If they do have a lucid moment, its temporary and they will go back to the delusions (Dieguez et al., 2007). Misoplegia is more severe than somatophrenia (Pearce, J. 2007). It is defined as a hatred for the affected limb which is usually presented by the following behaviors: shouting, swearing, or hitting the arm and leg. It can develop from prior somatophrenia, denial, or personification of that particular limb. Pearce (2007) reports that it is very rare and only 6 cases of its occurrence have been published. Misoplegia has been found to occur when there has been damage to three areas of the brain: the right parietal lobe, right optic thalamus, and/or the right thalamoparietal radiation (Dieguez et al., 2007 and Pearce, 2007). For all these cases, it is still unknown why some patients will show complete denial, will personify, or will show hatred for their affected limb(s). The mechanisms underlying these disorders need to be studied further before any conclusions are made. CAUSES OF ASOMATOGNOSIA Asomatognosia, whether defined as a specific disorder or as a broad category for various disorders, has generally been found to be caused by damage to the right parietal lobe

(see Figure 3). Damage to the right parietal lobe can be due to surgery, trauma to the head, or strokes (Dieguez et al., 2007). Strokes are cerebrovascular disorders that can be caused by either cerebral hemorrhaging or by cerebral ischemia (Pinel, 2006). A cerebral hemorrhage is when bleeding in the brain occurs due to the rupturing of blood vessels. Then this blood seeps into and damages the neural tissue surrounding that area. A cerebral ischemia occurs when the blood supply to area(s) of brain is disrupted. This can happen in three different ways: thrombosis, embolism, and/or arteriosclerosis. ASSESSMENT OF ASOMATOGNOSIA According to Dieguez et al. (2007), there is not one standard way of assessing for asomatognosia due to its temporary and changing nature. Therefore, it is very important to include interviews with family members and staff who will be with the patient for longer periods of time along with more formal assessments. There are various assessments that have been created to assess distortions of body schema. Generally, these include verbal questionnaires, observational rating scales, self-rating scales, normal and skewed mirrors, self-drawings (such as seen in case study 2), use of dolls/manikins, and tests of motor imagery. Bisiach, Vallar, Perani, and Berti (1986) tested body schema distortions by asking the patient to grasp his/her contralesional hand with their other hand. They would then grade their patient on a scale of 0-3 on their ability to complete the task. For example, if the patient was able to grasp their other hand without hesitation or further prompting, they would be given a 0. However, if they made no movement towards reaching the affected hand, they would be given a 3. Morin et al. (2002) adapted this scale slightly. They would show the patient the contralesional hand (usually the left one) and ask the patient what they were being shown. The scale used to grade the patients reaction was again from 0-3 as follows: 0 if they stated it was their left hand, 1 if they stated it was simply a hand or if they stated it was the doctors hand, but could admit that it was really theirs if they were asked directly, 2 if they only accepted that it was their hand if they were physically shown how it was attached to their

body, and 3 if the patient refused even after being shown how the hand was attached to their body. Other variations exist and can be as simple as asking the patient what is it that they are holding up while lifting the right arm first and then lifting the left and asking the same question. Or the doctor can show somebody elses hand to the client presenting it from the left and then the right side. The patient should show no delusions when someone elses hand is shown from the right but the reverse may be true if it is presented to them from their left side. Other such verbal questionnaires exist such as the one created by Cutting in 1978 (as cited in Dieguez et al., 2007) (see Table 1). Table 1: Cuttings (1978) verbal questionnaire used to assess for impaired body awareness. Possible Questions Disorder/Symptom Anosodiaphoria 1. Is it a nuisance? 2. How much trouble does it cause you? 3. What caused it? Nonbelonging 1. Do you ever feel that it does not belong to you? 2. Do feel that it belongs to someone else? Strange feelings 1. Do you feel the arm is strange or odd? Misoplegia 1. Do you dislike the arm? 2. Do you hate it? Personification 1. Do you ever call it names? Somesthetic/Kinesthetic 1. Do you ever feel it moves without your moving it yourself? Hallucinations 2. How big or strong is it? 3. How is the other arm? Phantom 1. Do you ever feel as if there was more than one arm/hand? supernumerary illusion 2. Do you ever feel a strange arm is lying beside you? 3. Do you ever feel you arm as separate from the real one? Or from you? Other tests include asking patients to draw how they perceive themselves and one using mirrors to show patients how the limbs are attached to the body. Another test is the Fluff test by Cocchini,Beschin, and Jehkonen (2001). With this test, the patient is blindfolded while cotton balls are spread on their left side. After this is completed, the blindfold is removed and the patient is asked to locate and remove all of the cotton balls.

TREATING ASOMATOGNOSIA Currently, there is no specific treatment for asomatognosia. Instead, the treatment will most likely focus on assessing the cause of the lesions (stoke, head injury, and etc.), treating the cause, and educating the patient and their family on the symptoms (Dieguez et al., 2007). Use of mirrors has been found to change asomatognosia (Arzy et al., 2006). Specifically, they can be used to show patients the continuity from their body to the affected limbs by having them look at the mirrors image while touching the patients missing limb.

CASE STUDY 1 Feinberg (2001) presents us with an example of one of his asomatognosia patients. Mirna suffered a stroke that caused severe frontoparietal damage, as seen in Figure 3. As a result, her left arm was paralyzed, and she reported symptoms of asomatognosia, claiming that her left arm did not belong to her. When Feinberg held her own arm up to her face, and asked her to identify it, she claimed vehemently that the arm belonged to Feinberg himself. When he showed her his own hands, she was able to correctly identify them as his. She was also able to correctly identify her own right arm. However, even when specifically shown that her hand was attached to her own body at the shoulder, she still claimed that her left hand belonged to the experimenter. This behavior is typical among patients with asomatognosia, and in some cases becomes more extreme or extravagant. For example, Feinberg also reports cases of patients with asomatognosia that personify the parts of their body they claim to belong to someone else.

Figure 3: Brain damage is represented by the shaded area2.

[2] Feinberg, T. E., (2001). Altered Egos: How the Brain Creates the Self. New York, Oxford University Press. CASE STUDY 2 Arzy et al. (2006) discuss a case study of a 51 year old who experienced a dizzy spell while working within her own home. After the dizzy spell lifted, the 51 years old felt like parts of her left arm were suddenly missing. She described that initially, she could see the table where her left arm had been resting and could still see the parts of her arm above her elbow only. She could not move her left arm or hand. After a few minutes, the feelings disappeared. She was asked to draw how she perceived her left arm right after her dizzy spell to when the strange feelings completely left her (see Figure 4). A neurological examination of the patient found many interesting results. MRI scans taken 12 days after the dizzy spell showed that the patient had suffered a mild stroke causing two small ischemic lesions in the premotor cortex and primary motor cortex (see Figure 5). The stroke had been due to a cerebral ischemia which had been caused by an embolism. CT scans however found everything to be normal. Further testing found that there was moderate left sided hypoesthesia of the arm and lower face.

Figure 4: The patient drew how she perceived her left hand before the dizziness spell, right after the dizziness spell, minutes after the dizziness spell until she was able to see and move her entire left arm3.

Figure 5: The MRI scans indicating the ischemic lesions in the right premotor cortex and primary motor cortex of the patient caused by a mild stoke3.

[3] Arzy, S., Overney, L., Landis, T., Blanke, O. (2006). Neural mechanisms of embodiment: Asomatognosia due to premotor cortex damage. Archives of Neurology. 63, 1022-1025. CASE STUDY 3 One patient admitted to the hospital for neurological testing earlier in the day woke up from a nap and fell out of his bed (Sacks, 1998). He refused to get back into bed and continued to focus on his left leg. When asked if he needed help to get back into bed he would refuse. He was then asked what was going on. He replied that when he had woken up from his nap, he had found a severed leg in the bed with him. It was cold, gruesome looking, and he was horrified at finding it there. He tried to throw it out his bed and fell out too! The patients story then, takes another turn. He tells that after falling out of the bed, the severed leg came after him and attached itself to him! After finishing his story, the patient turned against his leg and started to violently hit it. This third case is one example of how the young mans symptoms could lead him to be diagnosed with somatophrenia due to the delusions he had towards his leg and/or misoplegia due to anger and violence towards the leg. CASE STUDY 4 Another case study of misoplegia is described by Loetscher, Regard, and Brugger (2006), involving an older woman. At the age of 79, she was taken to the hospital due to various symptoms that had started to appear the past few weeks. These symptoms included: sudden mood changes, dizziness, cognitive decline, cold sensation in her left toes, gait problems, and abdominal pain. The initial neurological examination did not reveal any problem. However, a tumor that ranged from the right hippocampus to the medial regions of the right temporal gyrus and right temporal horn and parietal region was found in an MRI of her brain (see Figure 6).

Figure 6: The MRI image taken prior to surgery, revealing the tumor and lesions in the right hippocampus, medial regions of right temporal gyrus, and right temporal horn and parietal region4. As the examination continued, more symptoms became obvious. Those pertaining to misoplegia included talking to both her legs as if they were people. Specifically, shed treat her right leg as a friend while her left leg was an enemy that she wanted to get rid of. She called her left leg names, cursing its existence and even became violent towards it (see Figure 7). After surgery which removed the tumorous lesion, she still fought with her left leg and stated multiple times that she would have been happier if her leg would just die. Her fights with the left leg got to the point where she would leave bruises. As time passed, she showed changes in her attitude towards her left legcaressing it and talking to it in a friendlier mannerbut the attitude was quick to change and she should go back to fighting and acting in self-injurious ways. She also showed signs of anosognosia during this time (i.e. claiming she could walk and run despite being in a wheelchair). The patient died 6 weeks after surgery.

Figure 7: The patient in the process of hitting her left leg and cursing at it4. [4] Loetscher, T., Regard, M., and Brugger, P. (2006). Misoplegia : A review of the literature and a case without hemiplegia. Journal of Neurology, Neurosurgery, and Psychiatry. 77, 1099-1100.

CONCLUSION Asomatognosia is a neurological disorder caused by damage to the parietal lobe and results in an inability for the patient to recognize parts of their body as their own. Currently, little examination has been done into the treatment of this disorder, as it is predominantly temporary. While some of the conditions attached to, or labeled as asomatognosia do last for some duration, these cases are exceedingly rare. Future directions in this area include a movement for specificity and localization in lesion location as a method of better understanding how lesions to very specific areas of the brain affect perception and memory. More work needs to be done to understand why some patients simply deny parts of their body or play down their symptoms while others come to develop a hatred or deeper bond to the affected limb(s). Additionally, an understanding of the temporary nature of asomatognosia could offer great insight into brain plasticity as a mechanism for uncovering how the brain recovers function from brain damage due to strokes or other damage. Lastly, this area offers some far more abstract opportunities for research into the bio-neurological representation of the self, as the parts of the body are specifically unable to be recognized as belonging to the self. Is our self concept a result of exposure or familiarity? Or can the concept of self be localized to specific parts of the brain that can then be lesioned? Is it possible to destroy ones connection to ones own body, or is asomatognosia simply an artifact of contralateral/unilateral neglect? All are questions to be answered in the future.