Neuropsychologia 47 (2009) 1256–1260 Contents lists available at ScienceDirect Neuropsychologia journal homepage: www.elsevier.com/locate/neuropsychologia Self-observation reinstates motor awareness in anosognosia for hemiplegia Aikaterini Fotopoulou a,* , Anthony Rudd b , Paul Holmes b , Michael Kopelman c a Institute of Cognitive Neuroscience, University College, London, UK b Stroke Unit, St. Thomas’s Hospital, UK c King’s College London, Institute of Psychiatry, UK article info Article history: Received 4 August 2008 Received in revised form 17 December 2008 Accepted 7 January 2009 Available online 19 January 2009 Keywords: Anosognosia Motor awareness Body schema Body representation Right parietal cortex abstract We report a patient with severe anosognosia for hemiplegia, who recovered instantly and permanently when viewing herself in a video replay. We believe the observed dramatic reinstatement of the patient’s awareness related to her self-observation ‘from the outside’ (3rd person perspective) and ‘off-line’ (at a time later than the actual attempt to execute a movement); her anosognosia had been unaltered when she observed her plegic arm in her ipsilateral visual field (self-observation from a 1st-person perspective and ‘on-line’). To our knowledge, the role of self-observation in videos or mirrors has not being assessed in AHP to date. Our study provides preliminary evidence that, when right hemisphere damage impairs the ability to update one’s body representation, judgements relying on 3rd-person and off-line self-observation may be spared in some patients and may facilitate 1st person awareness. © 2009 Elsevier Ltd. All rights reserved. 1. Introduction In humans, central neurological damage may lead to con- tralateral hemiplegia. This may sometimes be accompanied by a higher-order impairment of body awareness which, similarly to the hemiplegia, concerns the contralateral side of the body. Patients may falsely believe that they can move their paralysed limbs despite blatant evidence to the contrary, and they may even claim that they have moved to an examiner, when no such movement has taken place. This symptom, termed anosognosia for hemiplegia (Babinski, 1914) (AHP; apparent unawareness of paralysis) is often a tran- sient phenomenon, with patients spontaneously recovering within days, weeks or months from onset. Nevertheless, the occurrence of AHP at the critical acute state following stroke may impede motor rehabilitation (Gialanella, Monguzzi, Santoro, & Rocchi, 2005) and limit accessibility to thrombolysis (Di Legge, Fang, Saposnik, & Hachinski, 2005). In addition, recent reviews suggest that approx- imately 30% of reported anosognosic patients remain unaware of their deficits beyond the acute phase of their illness (Orfei et al., 2007; Pia, Neppi-Modona, Ricci, & Berti, 2004). AHP occurs more frequently following right brain damage, usually in the frontopari- etal cortex, but it has also been reported following subcortical and left-hemisphere lesions (Orfei et al., 2007; Pia et al., 2004). * Corresponding author at: Institute of Cognitive Neuroscience, University College London, 17 Queen Square - London - WC1N 3AR, UK. Tel.: +44 207 7679 1177; fax: +44 20 7813 2835. E-mail address: a.fotopoulou@ucl.ac.uk (A. Fotopoulou). No available treatment exists for AHP, although temporary remis- sion has been reported following vestibular stimulation (Rubens, 1985). Patients with AHP typically remain anosognosic when their plegic arm is brought into the ipsilateral visual field. However, to our knowledge, self-observation from a 3rd person perspective has not being used in the treatment of AHP to date. We report a patient with anosognosia, who recovered instantly and permanently from her anosognosia after viewing herself in a video replay. We believe this dramatic reinstatement of awareness related to the observation of herself ‘from the outside’ (3rd person perspective), and poten- tially also to the observation of oneself at a time later than the actual attempt to execute a movement (‘off-line’). 2. Case report and methods LM was a 67-year-old right-handed woman, a retired publisher, with 15 years of education (premorbid IQ 114, as estimated by the Wechsler Test of Adult Reading (Wechsler, 2001). She was previously mobile and independent without any relevant medical history, other than untreated hypertension. She was found collapsed with a marked left-sided hemiplegia. Radiological examination confirmed a large right distal MCA infarct. Six days post-admission her GCS was 15. On neurological exami- nation she was found to be hypotonic, with absent reflexes, no tactile sensation, no pain, and 0/5 power in her left limbs. She showed some mild dysarthria, left lower facial weakness, left hemispatial neglect, left homonymous hemianopia and right gaze deviation. Her neuropsychological profile 6 days post-onset and at follow-up examinations is presented in Table 1. Fig. 1 shows LM’s CT and MRI scans 1 day and 1 year post-onset. The study was approved by the local NHS ethical committee and LM gave written informed consent. A formal awareness interview, including general questions (e.g. Can you move your left arm?) and confrontation (“Please, touch my hand with your left hand. Have you done it?”), was used to assess LM’s anosognosia (Berti, Ladavas, & Della 0028-3932/$ – see front matter © 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.neuropsychologia.2009.01.018