Mentalizing the body: spatial and social cognition in anosognosia for hemiplegia

Patients with anosognosia for hemiplegia after right-hemisphere stroke deny the existence of contralesional motor deficits. Besharati et al. show that such patients are impaired in social cognition tasks requiring 3(rd) person perspective-taking. A reduced ability to disengage from the 1(st) person perspective may explain the patients' reduced bodily self-awareness.Patients with anosognosia for hemiplegia after right-hemisphere stroke deny the existence of contralesional motor deficits. Besharati et al. show that such patients are impaired in social cognition tasks requiring 3(rd) person perspective-taking. A reduced ability to disengage from the 1(st) person perspective may explain the patients' reduced bodily self-awareness.Following right-hemisphere damage, a specific disorder of motor awareness can occur called anosognosia for hemiplegia, i.e. the denial of motor deficits contralateral to a brain lesion. The study of anosognosia can offer unique insights into the neurocognitive basis of awareness. Typically, however, awareness is assessed as a first person judgement and the ability of patients to think about their bodies in more 'objective' (third person) terms is not directly assessed. This may be important as right-hemisphere spatial abilities may underlie our ability to take third person perspectives. This possibility was assessed for the first time in the present study. We investigated third person perspective taking using both visuospatial and verbal tasks in right-hemisphere stroke patients with anosognosia (n = 15) and without anosognosia (n = 15), as well as neurologically healthy control subjects (n = 15). The anosognosic group performed worse than both control groups when having to perform the tasks from a third versus a first person perspective. Individual analysis further revealed a classical dissociation between most anosognosic patients and control subjects in mental (but not visuospatial) third person perspective taking abilities. Finally, the severity of unawareness in anosognosia patients was correlated to greater impairments in such third person, mental perspective taking abilities (but not visuospatial perspective taking). In voxel-based lesion mapping we also identified the lesion sites linked with such deficits, including some brain areas previously associated with inhibition, perspective taking and mentalizing, such as the inferior and middle frontal gyri, as well as the supramarginal and superior temporal gyri. These results suggest that neurocognitive deficits in mental perspective taking may contribute to anosognosia and provide novel insights regarding the relation between self-awareness and social cognition.