NEURO - Ch5 Right Hemisphere Disorders

Visual agnosia

An inability to appropriately perceive visual stimuli that results from damage to the central nervous system, not peripheral damage to the eyes or optic nerve.

Prosopagnosia

A neurologic deficit in the specific ability to cognitively process sensory information regarding the faces of others for the purposes of recognition.

Discourse

The exchange of communicative information between a speaker and a listener or the back-and-forth among individuals participating in conversation.

Simultagnosia

A neurologic disorder that produces the inability to visually perceive many details at once.

Achromatopsia

Color blindness. Also known as color agnosia.

Neglect

A general term used to describe a deficit in the ability to attend to sensory stimuli from one side of the body or the environment.

hemibody neglect

A deficit in the ability to attend to one side of the body. Also known as personal neglect.

hemispatial neglect

A deficit in the ability to attend to one side of the environment.

motor neglect

A condition of displaying diminished use of a neglected limb despite the limb being motorically intact.

extinction

A mild case of hemispatial neglect in which the affected individual can attend to stimuli within the neglected field of attention, but only with prompting.

asomatognosia

The condition in which an individual is unable to recognize or acknowledge a part of their own body (usually an extremity) as belonging to themselves.

somatophrenia

A deficit in the ability to perceive parts of one’s own body as belonging to oneself

capgras delusion

A neuropsychiatric deficit characterized by a belief that loved ones, significant others, or family members have been replaced by imposters.

fregoli delusion

A neuropsychiatric disorder in which the affected individual believes a familiar person is able to take on the guise of another person—at times, many other people—and can assume that other person’s exact appearance.

Normal right hemisphere functions include the following:

• Processing of nonlinguistic elements of communication such as prosody, facial expression, body language, and emotion

• Math/visuospatial skills such as perception of depth, distance, and shapes

• Localizing targets in space

• Identifying figure–ground relationships

• Processing melody of music

• Perception of macrostructure or gestalt

What is Right hemisphere disorder?

Right hemisphere disorders are a group of deficits or changes that occur following damage or pathology to a person’s right cerebral hemisphere.

What are Etiologies of right hemisphere disorders?

Etiologies of right hemisphere disorders include anything that damages the right hemisphere, including stroke, disease, trauma, seizures, infections, and toxicity. The type and severity of resulting deficits or disorders depend on the location and extent of damage. Degenerative diseases can also produce right hemisphere disorders, though usually in the presence of left hemisphere syndromes as well. This is because degenerative diseases usually affect both hemispheres simultaneously.

Communication deficits associated with right hemisphere damage include deficits in the following abilities:

• Facial recognition

• Comprehension of facial expression

• Production of facial expression

• Comprehension of meaning behind prosody

• Production of normal prosody

• Inferencing

• Discourse

Visuospatial deficits associated with right hemisphere damage include the following:

• Simultagnosia, which is the inability to visually perceive multiple details at one time

What is Cerebral achromatopsia?

Cerebral achromatopsia, which is color blindness resulting from trauma or damage to the cortex that causes the individual to see in shades of gray

Attention deficits associated with right hemisphere damage include the following:

• Neglect, which is the inability to attend to or recognize the body or environment contralateral to the lesioned hemisphere

• Hemibody neglect, which is the inability to attend to sensory information concerning one side of the body

• Hemispatial neglect, which is the inability to attend to sensory information from one side of the environment

• Asomatognosia, which is a condition in which an individual is unable to recognize or acknowledge a part of her own body (usually an extremity) as belonging to her

• Somatophrenia, a subtype of asomatognosia in which a person has the perception and belief that an extremity or side of his own body belongs to someone else

• Motor neglect, which is the diminished use of a neglected limb despite it being motorically intact

• Extinction, which is a mild form of hemispatial neglect in which a person is able to attend to objects within the field of neglect, but only with prompting

• Sustained and selective attention deficits, which can cause the affected individual to miss relevant information, become distracted by irrelevant stimuli, and further lose track of the topic of conversation

What must SLP’s understand in neuropsychiatric disorders?

Speech-language pathologists must understand and recognize neuropsychiatric disorders associated with right hemisphere damage because these can present alongside and interact with communication disorders.

Neuropsychiatric disorders that result from right hemisphere damage include the following:

• Anosognosia is the inability of the affected individual to recognize or realize that he has deficits. The affected individual usually blames failures in therapy on the speech-language pathologist or caregivers and explains away failures by refusing to acknowledge the deficits.

• Depression is common in any population following disease, stroke, surgery, or trauma. However, emotional changes in individuals with a right hemisphere disorder can go unnoticed or can be masked by other deficits.

• The Capgras delusion is the affected individual’s belief that loved ones, significant others, or family members have been replaced by imposters who look and sound like the original persons.

• The Fregoli delusion is the affected individual’s belief that a familiar person is able to take on the guise of another person, at times many other people, and assumes the other person’s exact appearance.

• Visual hallucinations are when an individual perceives something visually that does not truly exist or is not there. Visual hallucinations are caused by lesions or seizure activity in the posterior right hemisphere among the visual processing areas.

• Paranoid hallucinations are hallucinations that are perceived as threatening, ominous, or foreboding

Assessment of right hemisphere disorders usually includes the following techniques:

• A case history, which includes gathering information from medical charts, medical records, and interviews with the patient and family members

• Informal testing of cognitive deficits such as prosopagnosia, facial affect, prosody, inferencing, discourse, neglect, and attention deficits

• Formal testing for right hemisphere disorders, which usually assesses language abilities not tested in formal aphasia tests such as humor, metaphor, sarcasm, facial expression, and prosody

Treatment of right hemisphere disorders includes the following:

• Tasks that target expression and comprehension of facial expressions, prosody, discourse, pragmatics, neglect, attention, and anosognosia

• Environmental manipulations to reduce distractions might include closing the window blinds, turning off the television, instructing family members to speak clearly to the patient, one person speaking at a time, and speaking in short and easy-to-follow sentences while giving plenty of repetitions of important information and breaks for the patient to process what is being said

List and explain five functions of a normal right hemisphere

1. Processing and Expression of Emotion
   Involves understanding and expressing emotions through gestures, facial expressions, and body language.

2. Prosody
   Includes interpreting and producing the rhythm, pitch, stress, and intonation patterns of speech that convey emotional meaning and intent.

3. Visuospatial Skills
   Supports perception of depth, distance, shapes, and spatial relationships in the environment.

4. Figure-Ground Perception and Gestalt Processing
   Allows distinguishing a figure from its background and perceiving the overall pattern or “big picture.”

5. Cognitive and Pragmatic Integration
   Encompasses mathematical reasoning, appreciation of melody in music, and understanding the rules of discourse necessary for effective social and conversational communication.

Which surgical procedure led to a sudden resurgence of interest in the study of the right hemisphere during the 1960s?

The surgical procedure is Corpus commissurotomy, which is a procedure involving cutting the corpus callosum to receive intractable seizures. 

List three common etiologies of right hemisphere disorders.

Stroke, infection, and trauma

Where in the brain might a lesion produce prosopagnosia, and how does prosopagnosia affect communication?

Damage to the visual association area of the occipital lobe can produce prosopagnosia. This can affect communication because the person will not be able to recognize the faces of those he or she is communicating with.

How do deficits in inferencing and discourse affect communication and pragmatics?

Deficits in inferencing and discourse negatively affect communication and pragmatics of those with right-hemisphere disorders. These deficits limit the individual’s knowledge of the general topic of conversation, affect his or her ability to perceive nonlinguistic affect features of conversation (prosody, body language, facial expression), as well as reduce the person’s ability to assess the true purpose and meaning of the discourse. The deficits may also reduce the individual’s ability to infer the presence of any shared knowledge among communication partners, causing him or her to often state the obvious. Deficits in discourse also will negatively affect the individual’s ability to make conversational repairs.

How are hemibody neglect and hemispatial neglect different?

Hemibody neglect is the inability to attend to sensory information concerning one side of the body. Hemispatial neglect is the inability to attend to sensory information from one side of the environment.

How might neglect affect a patient’s life and overall prognosis?

Neglect might affect a patient’s life because he or she is not able to recognize or acknowledge the existence of the neglected side of the world or his or her own body. These individuals also may bump into objects; run a wheelchair into a wall; read only the print that is on the non-neglected side; and be unable to look, direct their attention to, or rotate their body to the neglected side of the world. Neglect may impact overall prognosis because of the disabling effects it causes for everyday living and caregiver burden.

Name three neuropsychiatric disorders that can occur as a result of right hemisphere damage.

Three neuropsychiatric disorders that can occur as a result of right hemisphere damage include anosognosia, capgras delusion, and fregoli delusion.

What are three usual components of assessment for right hemisphere disorders

Three usual components of assessment for right hemisphere disorders are: 

-taking an in-depth case history

-informally testing for cognitive abilities

-and formal testing of language abilities.

How can a speech-language pathologist informally assess comprehension and production of prosody?

A speech-language pathologist can informally assess comprehension of prosody:

• by repeating a phrase or sentence and varying the meaning of the phrase or sentence by altering the intonation and then asking the affected individual for interpretation of each varied production.

• the speech-language pathologist can then ask the patient to interpret the emotional meaning being conveyed.

• production of prosody can be informally assessed by listening to the connected speech of the individual and checking for an abnormal level of monotone, or by having the affected individual alter their prosody to convey different emotional meanings on a single utterance.

How can a speech-language pathologist informally assess neglect?

Therapists can informally assess neglect by using cancellation tasks, observation, line bisection, and line drawings. Specifically, cancellations tasks involve presenting the client with a sheet of paper with various stimuli printed on a page, and then they are asked to mark certain stimuli. For example, the clinician may ask the client to circle all of the Xs on a page covered in both Xs and Os.  Another form is line bisection, the SLP will draw a long horizontal line on a sheet of paper that centers the paper in front of the client, and then asks the client to put a mark in the center of the line. 

Another common method of assessment is to present the patient with a line drawing of a flower or clock, and then asking them to copy it on another piece of paper. 

A functional assessment of neglect can be added by observing the patient for signs of neglect as they go about activities of daily life. The Catherine Bergego Scale (CBS) is noteworthy in that it assesses an individual's performance within multiple areas of space and across multiple domains. 

Also observing he patient complete ADLs, and distributing blocks evenly on a baking pan.

How can a speech-language pathologist informally assess the four levels of attention?

A speech-language pathologist can informally assess sustained attention by having the patient sort playing cards by suit or color with no competing stimuli.

Sorting cards by suit and color can become a selective attention task by adding the radio or television in the background.

Alternating attention could be assessed by having the patient sort the cards by suit, then when given a cue, sort the cards by color or number, and then shift back to the initial task.

Divided attention can be assessed by asking the patient to sort cards in a specific way while simultaneously attending to a short story told by the speech-language pathologist.

Name two formal assessments for right hemisphere disorder.

Two formal assessments for right hemisphere disorder include the Right Hemisphere Language Battery and the Mini Inventory of Right Brain Injury. (Formal tests also include Communication Activities of Daily Living, Arizona Battery for Communication Disorders of Dementia, and Ross Information Processing Assessment)

How can a speech-language pathologist treat neglect in therapy?

A speech-language pathologist can treat neglect in therapy by using visual scanning therapy, in which the patient is required to shift his or her attention toward or into the neglected space when given heavy verbal cues.

Edgeness is another therapy technique that uses a flat container with raised edges (such as a baking pan) and small cubes or blocks distributed within the pan that the patient is asked to find.

How can a speech-language pathologist treat anosognosia in therapy?

A speech-language pathologist can treat anosognosia in therapy by counseling and coaxing the patient to recognize and take ownership of his or her deficits. A more direct approach can be taken when a video camera records a therapy session in which the patient is presented with a simple task that someone without the deficits would be able to successfully complete.

How can a speech-language pathologist treat discourse deficits in therapy?

A speech-language pathologist can treat discourse deficits in therapy by presenting the patient with short stories or pictures from magazines, newspapers, and websites and having the patient generate appropriate titles for the stories or pictures. Increasing the patient’s awareness of the listener’s needs, increasing awareness of social conventions and expectations, and increasing theory of mind may also treat discourse deficits.

Name two environmental manipulations a speech-language pathologist can use to reduce distractions.

Two environmental manipulations a speech-language pathologist can use to reduce distractions include closing the blinds or the windows, turning off the television or radio, and reducing clutter on the table or in the workspace.

Name two instructions a speech-language pathologist can give family members to facilitate communication with their loved one with a right hemisphere disorder.

Two instructions a speech-language pathologist can give family members to facilitate communication with their loved one with a right hemisphere disorder include instructing the family to speak clearly and one at a time to the patient with short and easy-to-follow sentences with plenty of repetitions and frequent breaks.

How do deficits in comprehension and production of facial expression affect communication?

Deficits in the comprehension and production of facial expressions can greatly impact social communication. Individuals with right-hemisphere damage often have particular difficulty accessing the emotional meaning of others’ facial expressions, when individuals cannot interpret others' expressions, they may misread emotions or intent, leading to inappropriate responses. If they cannot produce facial expressions, they may appear unengaged or indifferent, displaying what is known as a flat affect to their loved ones, which can cause misunderstandings and reduce emotional connection. 

How do deficits in comprehension and production of prosody affect communication?

Those with right hemisphere damage have difficulty using prosody to express their own emotions. Deficits in comprehension of prosody prevent individuals with right-hemisphere damage from fully accessing the emotional meaning of the prosodic component of an utterance, leading to literal interpretations of language. Deficits in the production of prosody also affect communication because these individuals are unable to communicate their emotional state to listeners through vocal tone or inflection, which makes them seem monotone and emotionless even though they still possess the full range of emotions