Dyschiria

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Dyschiria, also known as dyschiric syndrome, is a neurological disorder where one-half of an individual's body or space cannot be recognized or respond to sensations. [1] The term dyschiria is rarely used in modern scientific research and literature. Dyschiria has been often referred to as unilateral neglect, visuo-spatial neglect, or hemispatial neglect from the 20th century onwards. Psychologists formerly characterized dyschiric patients to be unable to discriminate or report external stimuli. This left the patients incapable of orienting sensory responses in their extrapersonal and personal space. Patients with dyschiria are unable to distinguish one side of their body in general, or specific segments of the body. There are three stages to dyschiria: achiria, allochiria, and synchiria, in which manifestations of dyschiria evolve in varying degrees. [1]

Contents

The dyschiric syndrome was defined in the early 19th century by Ernest Jones, a Welsh psychiatrist, and has encapsulated several explanations of theoretical mechanisms for each stage. [1] Over the course of time, the decreased significance of dyschiria's biopsychological influence led to its replacement by 'neglect' under neurological disorders in neuropsychology. [2]

Dyschiric patients have deficiencies in motor, sensory, visual, and introspective zones of consciousness. These symptoms are associated with brain lesions, hysteria, and somatoparaphrenia which all affect cognition. [3] [4] In clinical studies, dyschiria is also referred to as the mislocalization of sensations (visual, auditory, and tactile) to the opposite half of the body which can be both unilateral and bilateral. [5]

Treatment is limited and unestablished clinically to be proven effective for dyschiric patients, while rehabilitation methods cannot sustain stable effects. Therapeutic options majorly consist of virtual reality (VR), neglected field eye patching, and prismatic adaptation (PA) alongside other rehabilitation therapies. [5]

History

The findings of dyschiria complexly align with cases studying syndromes of spatial neglect and related disorders that have been published in medical literature in the early 19th century. [6] Dr. Ernest Jones proposed the three stages of dyschiria as a mental syndrome in 1909. Jones studied the initial case of achiria alongside the phenomena of allochiria perceived by French psychologist Pierre Janet (1899) and Austrian neurologist Heinrich Obersteiner (1882), respectively. [7] [8] These independent cases defined the dyschiric syndrome and redefined allochiria.

From the 20th century onwards, "dyschiria" had been replaced by "unilateral neglect," "hemispatial neglect," and other related neurological disorders. "Unilateral neglect" replaced "dyschiria" following Austrian neurologist Marcel Kinsbourne's publication on the model mechanisms of unilateral spatial neglect. The study had a greater theoretical influence than previous experiments on dyschiria. [2]

Neglect disorders have become one of the major concerns in the study of neuropsychology. Neglect is the umbrella term for classification of neurological disorders of distinct subtypes including the visual, somatosensory, motor, extrapersonal, personal, and representational subdivisions. [9] Therefore, diverse neurological mechanisms have since then been proposed to investigate and explain higher cognitive functioning in the clinical study of neglect disorders. Symptom severity, pathophysiology, modality and chronology of neglect disorders also enhance the understanding of the neural networks in the brain of patients.

Types

There are three forms of dyschiria in the corresponding stages: achiria, allochiria, and synchiria, that manifest the neurological disorder in distinct capacities of sensory, motor and introspective recognition. [1] Each stage of dyschiria has been theorized to consist of various biological and psychological mechanisms.

Achiria

Unknown awareness and knowledge of the side of the stimulus is the earliest sign of achiria. Effective location of the point, nature, and intensity of stimulation is possible by the patient; with the exclusion of the side where the stimulus is applied. [10]

Sensations that are tactile cannot be carried out by patients with motor deficits, unless the limb is specified without "left" or "right" descriptions. Involuntary and habitual movements of the same limb, such as reflex mechanisms, can be performed as regular. Despite this, the functioning of this limb becomes more imprecise when a more conscious and directed effort is required. Patients experiencing achiria have lost the memory of feeling the affected body part, regardless of having the ability to recognize its existence. This experience is closely associated with the attitude of "depersonalization" felt by patients who have severe forms of hysterical anesthesia. [1]

Theoretical Mechanism: Paradoxical Cleavage

Senses can be categorized into two types: memory-focused and aesthesic. [1] Memory-focused senses are those obtained through previous experiences (e.g. knowing the difference between left and right). Aesthesic senses are obtained through ongoing experiences (e.g. smell and touch). Both senses can be damaged by functional disorders, however the time taken for recovery and reacquisition the senses can differ among the two groups.

In recovery from functional disorders, aesthesic senses usually recover quicker than memory-focused senses. Dr. Ernest Jones described this variation as a "paradoxical cleavage" and theorized it as the cause of achiria. Earlier recovery of tactile sensations relative to recognition between left and right sides underscores achiric symptoms. [1]

Allochiria

Being able to recognize the precise location of the stimulus on the corresponding position on the contralateral side of the body is referred to as allochiria. The location to which the stimulus is pointed on the corresponding opposite half of the body is done with exact symmetry. [1]

If patients are asked to carry out motor responses on the affected limb, they will instantly direct the movement of the opposite limb with full conviction. These confusions occur in bilateral allochiria. However, the affected limb can only be directed using its opposite direction (i.e. using the right hand requires the term "left" to be used) or it loses physiological function in unilateral allochiria.

Allochiric patients do not have the full ability to feel the affected limb in unilateral senses. The affected limb can only be felt on the opposite side and rarely on the correct half of the body as directed in movement. These patients may feel a "dead" limb and an "active" limb on the unaffected side of the body, while the affected half is seldom felt at all. Often, patients will feel that they only have one limb out of a pair on the unaffected side of the body. [1]

Bilateral allochiric patients have the mental capacity to feel both limbs on both sides of the body, only when it is asymmetrically commanded.

Theoretical Mechanism: Central Nervous System Damage

Tactile allochiria is present in individuals with damage to the central nervous system. [11] A study found 20 patients with cerebral hemorrhage unable to correctly localize tactile stimulation. When pinched on their arms, they incorrectly localized it to the corresponding area on the opposite arm. The same result was obtained when participants were exposed to other forms of tactile stimulation (e.g. exposure of the arm to cold/hot objects and vibration).

Brain lesions or other forms of brain damage (often caused by strokes) can lead to neglect of one's contralesional space. Information from the left and right egocentric spaces is principally understood by the neurons of the right parietal cortex. The right region is also weakly managed by the neurons of the left parietal cortex. [12]

Damage to the right parietal cortex is thus more severe as it solely maintains the attention towards the left space. [13] This makes neglect of the left space more prevalent as there is no mitigating component. The neglect caused by the lesion does not undermine the detection of tactile sensations, however hinders tactile localization. When stimulated by touch on the contralesional arm, the touch is detected, however the location of contact is transposed by the patient to the ipsilesional arm as the contralesional space cannot be acknowledged. [10]

Synchiria

Recognition of stimulus in both corresponding sides of the body as two concurrent sensations, when only applied to one affected part, is known as synchiria. In terms of motor response, the patient carries out movement on both sides of the body simultaneously even when asked to conduct motion on the affected side. This movement is only felt by the affected side of the patient's body. [1]

Introspectively, the patient is under the impression that they are moving their affected limb and is unable to differentiate between the two halves of their body. According to Dr. Ernest Jones, patients could feel the affected side being displaced and shifting between the two halves of the median plane of their body.

Theoretical Mechanism: Brain Lesions

The presence of synchiria is attributed to brain lesions. A study on a patient with a brain lesion on their left hemisphere showed detection of touch to be possible, lacking accurate identification of the point of contact. Specifically, he claimed to have experienced tactile sensation on both his left (ipsilesional) and right (contralesional) hands, when only his left hand was stimulated.

It is suggested that there are two pathways for somatosensory activity. The first is the contralateral pathway, where each hemisphere receives sensory information from and transmits motor information to their opposite egocentric spaces (i.e., the left side of the body to the right hemisphere). [14] The second, the ipsilateral pathway, allows for the transmission of information along the same side of the body (i.e., the left side of the body to the left hemisphere). [15]

In a healthy individual, when a hand is stimulated by touch, there is increased brain activity in the contralateral hemisphere, and decreased activity in the ipsilateral hemisphere. [16] This suggests the presence of mechanisms to inhibit the hemispheres from processing ipsilateral sensations. This inhibition is necessary to discriminate between the points of contact. The absence or damage of this inhibition is theorized to result in the exhibition of synchiria. Despite there being one tactile stimulation, the sensory information is processed by both hemispheres. This hinders one's ability to localize the touch to one hand and instead results in them feeling the sensation on both hands. [11] [17]

Recovery and Therapies

No treatment is established to be entirely effective on patients with dyschiria and related neglect disorders as the functioning mechanisms of the syndromes are varied. Therapeutic options are unable to maintain stable positive effects and are difficult to transfer for daily-life usage with certainty. Major treatments for dyschiria include virtual reality (VR), neglected field eye patching, and prismatic adaptation (PA). [5]

Virtual Reality (VR)

Virtual reality allows for the simulation of daily life circumstances to rehabilitate control of limbs, eyes, and head movement. This virtual simulation encourages transformations of postural shifts for patients. [18] Improvements in body coordination and sensations in daily-life activities can be practiced as patients achieve targets for movement with varying difficulties through the virtual simulation. VR increases body awareness in neglect disorders like dyschiria with results persisting over five months. [19]

Neglected Field Eye Patching

Neglected field eye patching covers the eye on the affected side of the body through an obstructing spectacle lens or glasses. The eye patch can be placed on either hemifield of the affected eye depending on the patient's weakness in spatial neglect. [20] The covered eye results in hemifield occlusion of vision which enables the individual to focus their awareness on the contralateral space using the deficient side of the body. [21] [22]

Prismatic Adaptation (PA)

Prismatic adaptation therapy involves the production of an optical displacement in patients through prismatic goggles. Patients with prismatic goggles are required to perform visual target tasks such as pointing and throwing. This therapy can lead to the correction of biased body representation, however prismatic adaptation therapy may only focus on motor-intention responses of neglect and dyschiria than space perceptions. [23]

Other rehabilitation therapies include [5] [24]

Some recovery protocols are used in conjunction to create amplified positive results. Neck muscle vibration technique alongside simultaneous visual exploration training resulted in sound enhancements for patients with spatial neglect. [25]

Future Development

The phenomena of dyschiria on body representation require further investigation for the development of theories and mechanisms around neuropsychological dissociations in concepts of the body schema and body image. [4] [26] These various concepts coincide with the nature of neglect syndromes akin to dyschiria to better understand the functioning of the brain.

Related Research Articles

Hemiparesis, or unilateral paresis, is weakness of one entire side of the body. Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke.

Alien hand syndrome (AHS) or Dr. Strangelove syndrome is a category of conditions in which a person experiences their limbs acting seemingly on their own, without conscious control over the actions. There are a variety of clinical conditions that fall under this category, which most commonly affects the left hand. There are many similar terms for the various forms of the condition, but they are often used inappropriately. The affected person may sometimes reach for objects and manipulate them without wanting to do so, even to the point of having to use the controllable hand to restrain the alien hand. Under normal circumstances however, given that intent and action can be assumed to be deeply mutually entangled, the occurrence of alien hand syndrome can be usefully conceptualized as a phenomenon reflecting a functional "disentanglement" between thought and action.

<span class="mw-page-title-main">Parietal lobe</span> Part of the brain responsible for sensory input and some language processing

The parietal lobe is one of the four major lobes of the cerebral cortex in the brain of mammals. The parietal lobe is positioned above the temporal lobe and behind the frontal lobe and central sulcus.

Anosognosia is a condition in which a person with a disability is cognitively unaware of having it due to an underlying physical condition. Anosognosia results from physiological damage to brain structures, typically to the parietal lobe or a diffuse lesion on the fronto-temporal-parietal area in the right hemisphere, and is thus a neuropsychiatric disorder. A deficit of self-awareness, it was first named by the neurologist Joseph Babinski in 1914.

<span class="mw-page-title-main">Hemispatial neglect</span> Medical condition

Hemispatial neglect is a neuropsychological condition in which, after damage to one hemisphere of the brain, a deficit in attention and awareness towards the side of space opposite brain damage is observed. It is defined by the inability of a person to process and perceive stimuli towards the contralesional side of the body or environment. Hemispatial neglect is very commonly contralateral to the damaged hemisphere, but instances of ipsilesional neglect have been reported.

Monoplegia is paralysis of a single limb, usually an arm. Common symptoms associated with monoplegic patients are weakness, numbness, and pain in the affected limb. Monoplegia is a type of paralysis that falls under hemiplegia. While hemiplegia is paralysis of half of the body, monoplegia is localized to a single limb or to a specific region of the body. Monoplegia of the upper limb is sometimes referred to as brachial monoplegia, and that of the lower limb is called crural monoplegia. Monoplegia in the lower extremities is not as common of an occurrence as in the upper extremities. Monoparesis is a similar, but less severe, condition because one limb is very weak, not paralyzed. For more information, see paresis.

<span class="mw-page-title-main">Caloric reflex test</span> Test of the vestibulo-ocular reflex

In medicine, the caloric reflex test is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water or air into the external auditory canal. This method was developed by Robert Bárány, who won a Nobel prize in 1914 for this discovery.

<span class="mw-page-title-main">Foix–Chavany–Marie syndrome</span> Medical condition

Foix–Chavany–Marie Syndrome (FCMS), also known as bilateral opercular syndrome, is a neuropathological disorder characterized by paralysis of the facial, tongue, pharynx, and masticatory muscles of the mouth that aid in chewing. The disorder is primarily caused by thrombotic and embolic strokes, which cause a deficiency of oxygen in the brain. As a result, bilateral lesions may form in the junctions between the frontal lobe and temporal lobe, the parietal lobe and cortical lobe, or the subcortical region of the brain. FCMS may also arise from defects existing at birth that may be inherited or nonhereditary. Symptoms of FCMS can be present in a person of any age and it is diagnosed using automatic-voluntary dissociation assessment, psycholinguistic testing, neuropsychological testing, and brain scanning. Treatment for FCMS depends on the onset, as well as on the severity of symptoms, and it involves a multidisciplinary approach.

Pallesthesia, or vibratory sensation, is the ability to perceive vibration. This sensation, often conducted through skin and bone, is usually generated by mechanoreceptors such as Pacinian corpuscles, Merkel disk receptors, and tactile corpuscles. All of these receptors stimulate an action potential in afferent nerves found in various layers of the skin and body. The afferent neuron travels to the spinal column and then to the brain where the information is processed. Damage to the peripheral nervous system or central nervous system can result in a decline or loss of pallesthesia.

Body schema is an organism's internal model of its own body, including the position of its limbs. The neurologist Sir Henry Head originally defined it as a postural model of the body that actively organizes and modifies 'the impressions produced by incoming sensory impulses in such a way that the final sensation of body position, or of locality, rises into consciousness charged with a relation to something that has happened before'. As a postural model that keeps track of limb position, it plays an important role in control of action.

Tactile discrimination is the ability to differentiate information through the sense of touch. The somatosensory system is the nervous system pathway that is responsible for this essential survival ability used in adaptation. There are various types of tactile discrimination. One of the most well known and most researched is two-point discrimination, the ability to differentiate between two different tactile stimuli which are relatively close together. Other types of discrimination like graphesthesia and spatial discrimination also exist but are not as extensively researched. Tactile discrimination is something that can be stronger or weaker in different people and two major conditions, chronic pain and blindness, can affect it greatly. Blindness increases tactile discrimination abilities which is extremely helpful for tasks like reading braille. In contrast, chronic pain conditions, like arthritis, decrease a person's tactile discrimination. One other major application of tactile discrimination is in new prosthetics and robotics which attempt to mimic the abilities of the human hand. In this case tactile sensors function similarly to mechanoreceptors in a human hand to differentiate tactile stimuli.

<span class="mw-page-title-main">Somatosensory system</span> Nerve system for sensing touch, temperature, body position, and pain

In physiology, the somatosensory system is the network of neural structures in the brain and body that produce the perception of touch, as well as temperature (thermoception), body position (proprioception), and pain. It is a subset of the sensory nervous system, which also represents visual, auditory, olfactory, gustatory and vestibular stimuli.

Extinction is a neurological disorder that impairs the ability to perceive multiple stimuli of the same type simultaneously. Extinction is usually caused by damage resulting in lesions on one side of the brain. Those who are affected by extinction have a lack of awareness in the contralesional side of space and a loss of exploratory search and other actions normally directed toward that side.

<span class="mw-page-title-main">Allochiria</span> Medical condition

Allochiria is a neurological disorder in which the patient responds to stimuli presented to one side of their body as if the stimuli had been presented at the opposite side. It is associated with spatial transpositions, usually symmetrical, of stimuli from one side of the body to the opposite one. Thus a touch to the left side of the body will be reported as a touch to the right side, which is also known as somatosensory allochiria. If the auditory or visual senses are affected, sounds will be reported as being heard on the opposite side to that on which they occur and objects presented visually will be reported as having been presented on the opposite side. Often patients may express allochiria in their drawing while copying an image. Allochiria often co-occurs with unilateral neglect and, like hemispatial neglect, the disorder arises commonly from damage to the right parietal lobe.

Amorphosynthesis, also called a hemi-sensory deficit, is a neuropsychological condition in which a patient experiences unilateral inattention to sensory input. This phenomenon is frequently associated with damage to the right cerebral hemisphere resulting in severe sensory deficits that are observed on the contralesional (left) side of the body. A right-sided deficit is less commonly observed and the effects are reported to be temporary and minor. Evidence suggests that the right cerebral hemisphere has a dominant role in attention and awareness to somatic sensations through ipsilateral and contralateral stimulation. In contrast, the left cerebral hemisphere is activated only by contralateral stimuli. Thus, the left and right cerebral hemispheres exhibit redundant processing to the right-side of the body and a lesion to the left cerebral hemisphere can be compensated by the ipsiversive processes of the right cerebral hemisphere. For this reason, right-sided amorphosynthesis is less often observed and is generally associated with bilateral lesions.

Supernumerary phantom limb is a condition where the affected individual believes and receives sensory information from limbs of the body that do not actually exist, and never have existed, in contradistinction to phantom limbs, which appear after an individual has had a limb removed from the body and still receives input from it.

Many types of sense loss occur due to a dysfunctional sensation process, whether it be ineffective receptors, nerve damage, or cerebral impairment. Unlike agnosia, these impairments are due to damages prior to the perception process.

Hemimotor neglect or simply motor neglect is a neuropsychological condition that occurs after damage to one hemisphere of the brain, characterized by a failure of spontaneous use of upper and lower limbs on one side of body. It occurs in the absence of paralysis, pyramidal syndromes, extrapyramidal symptoms, strength and primary sensory deficit.

<span class="mw-page-title-main">Tactile hallucination</span>

Tactile hallucination is the false perception of tactile sensory input that creates a hallucinatory sensation of physical contact with an imaginary object. It is caused by the faulty integration of the tactile sensory neural signals generated in the spinal cord and the thalamus and sent to the primary somatosensory cortex (SI) and secondary somatosensory cortex (SII). Tactile hallucinations are recurrent symptoms of neurological diseases such as schizophrenia, Parkinson's disease, Ekbom's syndrome and delirium tremens. Patients who experience phantom limb pains also experience a type of tactile hallucination. Tactile hallucinations are also caused by drugs such as cocaine and alcohol.

<span class="mw-page-title-main">Achiria</span> Medical condition

Achiria, also referred to as "Simple Allochiria", is a neurological disorder in which a patient is unable to recognise or perceive one side of their body. It is oftentimes associated with dyschiria, also known as a form of unilateral neglect or hemispatial neglect. The term achiria is seldom used in modern scientific literature.

References

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  2. 1 2 Bisiach, Edoardo; Berti, Anna (1987), "Dyschiria. An Attempt at its Systemic Explanation", Advances in Psychology, Elsevier, vol. 45, pp. 183–201, doi:10.1016/s0166-4115(08)61713-6, ISBN   978-0-444-70193-0 , retrieved 2022-03-29
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  11. 1 2 Medina, Jared; Coslett, H. Branch (2016-02-17). "What can errors tell us about body representations?". Cognitive Neuropsychology. 33 (1–2): 5–25. doi:10.1080/02643294.2016.1188065. ISSN   0264-3294. PMC   5398312 . PMID   27386744.
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  14. ↑ Ishii, Daisuke; Ishibashi, Kiyoshige; Yuine, Hiroshi; Takeda, Kotaro; Yamamoto, Satoshi; Kaku, Yuki; Yozu, Arito; Kohno, Yutaka (2021-08-17). "Contralateral and Ipsilateral Interactions in the Somatosensory Pathway in Healthy Humans". Frontiers in Systems Neuroscience. 15: 698758. doi: 10.3389/fnsys.2021.698758 . ISSN   1662-5137. PMC   8415971 . PMID   34483851.
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  20. ↑ Sugimoto, Satoshi; Fujino, Yuji (2017). "Neglected-Field Eye Patching Improves Visual Inattention in Hemispatial Neglect: A Case Study". Progress in Rehabilitation Medicine. 2: n/a. doi:10.2490/prm.20170012. ISSN   2432-1354. PMC   7365186 . PMID   32789219.
  21. ↑ Aparicio-López, Celeste; García-Molina, Alberto; García-Fernández, Juan; Lopez-Blazquez, Raquel; Enseñat-Cantallops, Antonia; Sánchez-Carrión, Rocío; Muriel, Vega; Tormos, Jose María; Roig-Rovira, Teresa (2015-03-21). "Cognitive rehabilitation with right hemifield eye-patching for patients with sub-acute stroke and visuo-spatial neglect: A randomized controlled trial". Brain Injury. 29 (4): 501–507. doi:10.3109/02699052.2014.995230. ISSN   0269-9052. PMID   25565480. S2CID   43756226.
  22. ↑ Smania, Nicola; Fonte, Cristina; Picelli, Alessandro; Gandolfi, Marialuisa; Varalta, Valentina (2013). "Effect of Eye Patching in Rehabilitation of Hemispatial Neglect". Frontiers in Human Neuroscience. 7: 527. doi: 10.3389/fnhum.2013.00527 . ISSN   1662-5161. PMC   3759299 . PMID   24032011.
  23. ↑ Fortis, Paola; Chen, Peii; Goedert, Kelly M.; Barrett, Anna M. (2011-10-05). "Effects of prism adaptation on motor-intentional spatial bias in neglect". NeuroReport. 22 (14): 700–705. doi:10.1097/WNR.0b013e32834a3e20. ISSN   0959-4965. PMC   3165096 . PMID   21817924.
  24. ↑ Baytimur, Emre & Hazar, Ceren. (2016). A Literature Review: Recovery in Spatial Neglect.
  25. ↑ Schindler, I., Kerkhoff, G., Karnath, H. O., Keller, I., & Goldenberg, G. (2002). Neck muscle vibration induces lasting recovery in spatial neglect. J Neurol Neurosurg Psychiatry, 73, 412-419.
  26. ↑ de Vignemont, Frederique (2010-02-01). "Body schema and body image—Pros and cons". Neuropsychologia. The Sense of Body. 48 (3): 669–680. doi:10.1016/j.neuropsychologia.2009.09.022. ISSN   0028-3932. PMID   19786038.
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