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Effects of emotional face cueing on line bisection
in neglect: A single case study
Marco Tamietto , Luca Latini Corazzini , Lorenzo Pia , Marina Zettin ,
Maurizio Gionco & Giuliano Geminiani
To cite this article: Marco Tamietto , Luca Latini Corazzini , Lorenzo Pia , Marina Zettin ,
Maurizio Gionco & Giuliano Geminiani (2005) Effects of emotional face cueing on line bisection
in neglect: A single case study, Neurocase, 11:6, 399-404, DOI: 10.1080/13554790500259717
To link to this article: http://dx.doi.org/10.1080/13554790500259717

Published online: 16 Feb 2007.

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Neurocase (2005) 11, 399–404
Copyright © Taylor & Francis LLC
ISSN: 1355-4795 print
DOI: 10.1080/13554790500259717

Effects of emotional face cueing on line bisection in neglect:
A single case study
NNCS

MARCO TAMIETTO 1,2 , LUCA LATINI CORAZZINI 1,2 , LORENZO PIA 1,2 , MARINA ZETTIN 2,3 , MAURIZIO GIONCO 4
and GIULIANO GEMINIANI 1,2
Faces and Emotions Modulate Spatial Neglect

1

Department of Psychology, University of Turin, Italy
Center for Cognitive Science, University of Turin, Italy
3
Puzzle Center for Neurocognitive Rehabilitation, Turin, Italy
4
Department of Neurology and Rehabilitation, Mauriziano Hospital Umberto I, Turin, Italy
2

One patient with left neglect (FM) and four right brain-damaged controls were tested on a line bisection task with pictures of neutral and
emotional faces as unilateral cues. We thus manipulated the attentional salience of the cues (higher for emotional and lower for neutral
faces) while keeping constant their physical dimensions. Our findings showed that left emotional faces were more effective than left neutral
faces in reducing bisection errors only in FM. These data indicate that in the neglected hemispace cues bias attention rather than simply
altering the perceptual point of balance of the line in the horizontal plane.

Introduction
Patients with unilateral spatial neglect tend to ignore (i.e.,
neither react to nor search for) stimuli in the contralesional
hemispace. A typical clinical test for the diagnosis of
neglect is the line bisection task where subjects are asked to
mark the midpoint of a horizontal line (Schenkenberg et al.,
1980). Generally, the rightward bisection bias shown by
neglect patients tends to decrease with unilateral left cues
and is enhanced with unilateral right cues (Riddoch and
Humphreys, 1983). This effect is usually obtained by placing either numbers or letters at the left or right end of the
line and asking subjects to pay attention to them (reading
them out) prior to bisection. Despite its empirical consistency, the explanation for the cueing effect is still the subject of debate. Indeed, several authors have explained
cueing effects in terms of attentional mechanisms, whereas
other authors have challenged this view, proposing a perceptual account (Fischer, 2001). The former hypothesis
posits that a cue draws attention to that side, thereby rendering the cued side more salient. As a result of this increased
Received 15 March 2005; accepted 17 July 2005
This work was supported by a grant from the Ordine Mauriziano
di Torino to Marco Tamietto.
We are grateful to Anna Berti for valuable comments on an earlier
version of this manuscript. Thanks also to Patrizia Gindri for help in
testing patients. Special thanks to Tiziana Zilli for technical support
in mapping brain lesions with MRIcro. Giuliano, Lorenzo, Luca,
and Marco wish to dedicate this study to the beloved memory of
Michele Girardi: Take care, ‘Don Michele’.
Address correspondence to Marco Tamietto, Dipartimento di
Psicologia, Università di Torino, Via PO 14, 10123, Torino, Italy.
E-mail: tamietto@psych.unito.it

salience, the length of the cued side is overestimated and the
mark is placed toward that side (Milner et al., 1992; Smania
et al., 1998; Pouget and Driver, 2000; Olk and Harvey,
2002). Conversely, the latter interpretation points out that,
since cues are placed beyond the true endpoint of the line,
they extend the line’s horizontal extent by several millimeters. This misperception of the line’s length, induced by the
alteration in the perceptual point of balance of the stimulus
in the horizontal plane, explains the cueing effect without
the need of postulating any attentional shift (Mattingley et al.,
1993; Fischer, 1994).
Disentangling attentional from perceptual interpretations
has been particularly problematic with unilateral cueing, as it
is impossible to separate the relative contributions of an
attentional manipulation from those caused by the alteration
of the perceptual point of balance when the same cue is used.
One way to empirically contrast attentional and perceptual
accounts in a line bisection task with unilateral cues is to vary
the attentional salience of the cues while keeping their physical extent constant.
Previous studies showed that emotional faces have a special advantage over neutral faces in summoning spatial
attention (Hansen and Hansen, 1988; Öhman et al., 2001;
Vuilleumier et al., 2001; Vuilleumier & Schwartz, 2001).
This is probably due to the high biological and social value
of emotional stimuli for survival and adaptive behavior
(Adolphs, 2002). In the present study we have thus used
neutral and emotional faces of the same size as unilateral left
or right cues to address the issue of the underlying mechanisms, attentional or perceptual, responsible for the cueing
effect in neglect. By considering the foregoing alternative
explanations of the cueing effect, we can formulate the following hypotheses: if the cueing effect works through biasing

400

Tamietto et al.

attention, we should observe a modulation of the line bisection error as a function of the salience conveyed by the cues.
That is, emotional cues should be more effective than neutral
face cues and this should be true for contralesional cues in
particular. If, conversely, the cueing effect is caused by a perceptual alteration of the point of balance, we should expect a
comparable influence of all cues, whatever their specific content, as they all have the same dimensions.

Method
Case report
We studied patient FM, a 73-year-old, right-handed Caucasian woman with chronic unilateral right brain damage from
neoplasia (Figure 1). In August 2002 FM was admitted to the
Mauriziano Hospital Umberto I of Turin because of sudden
and acute hemicranias in the right posterior hemisphere resistant to analgesic therapies. On neurological examination she
had mild left arm paresis with decreased touch sensation.
There was no gaze palsy but she tended to orient her eyes
and head to the right. A CT scan performed the same day
demonstrated a low attenuation area in the right parietal lobe,

consistent with neoplasia. Subsequent T1 and T2 weighted
MRI scans performed 5 days later confirmed the diagnosis
and showed a prevailing involvement of the underlying white
matter. When tested in the following days she showed severe
left neglect in all the tasks composing a battery for the diagnosis of neglect, which included: the line cancellation test
(Albert, 1973), the letter cancellation test (Diller & Weinberg,
1977), a sentence-reading test, and the line bisection test
(Schenkenberg et al., 1980). Face perception and emotional
processing from facial expressions were also tested using,
respectively, the Benton Facial Recognition Test (BFRT)
(Benton et al., 1983) and the Ekman 60 Faces Test (ESFT)
(Young et al., 2002). FM was aware of her deficits and
cooperative.

Control subjects
Four patients with unilateral right brain damage and no sign
of neglect in any of the tasks served as control group.
Demographic, clinical, and neuropsychological data of FM
and the control patients are summarized in Table 1. All
patients provided written informed consent approved by the
Ethical Committee of the University of Turin, Italy.

Fig. 1. Lesion reconstruction in the neglect patient FM, mapped using MRIcro software (Rorden & Brett, 2000).
Table 1. Demographic, clinical, and neuropsychological data of the patients
Patient Sex Age

Lesion

FM
FG
MD
MG
BN

T-O-P
Fr-T
BG-EC-Ins
Fr-T-P
IC-Ins-BG

F
F
M
M
M

73
77
71
60
62

Etiology Onset (days) MMSE VFD SRT
N
I
I
I
I

10
22
13
213
21

27.07
26.03
25.7
30
30

2–3
0–0
0–0
0–0
0–0

LBT M
(SD)

1/5 45.6 (14)
5/5 0.7 (0.93)
5/5 3.15 (1.93)
5/5 3.1 (2.4)
5/5 2.5 (3.1)

Diller L-R

Albert L-R

0–23
48–50
52–52
47–49
52–51

0–11
18–18
18–18
18–18
18–18

BFRT* ESFT
41
44
47
43
NA

45
51
50
46
NA

Abbreviations: BFRT = Benton Facial Recognition Test (cut-off = 37), *the stimuli were arranged centrally along the vertical meridian; ESFT = Ekman 60
Faces Test (cut-off = 42); Etiology: I = Ischemia, N = Neoplasia; LBT = line bisection test (mean (standard deviation) rightward deviation in mm on 10 lines);
Lesion: BG = basal ganglia; EC = external capsule; Fr = frontal; IC = internal capsule; Ins = insula; O = occipital; P = parietal; T = temporal; MMSE = Mini
Mental State Examination (Folstein, Folstein, & McHugh, 1975); NA = not available; SRT = sentence reading test (5 sentences); VFD = visual field defects
within the contralesional hemispace measured on the standard confrontation test (the two values refer to the upper and lower quadrants, respectively), scores
ranged from normal vision (0) to severe defect (3) (Bisiach, Cappa & Vallar, 1983); Diller = cancelled targets in the left hemispace (L) – cancelled targets in
the right hemispace (R), (number of total targets per hemispace = 52); Albert = cancelled targets in the left hemispace (L) – cancelled targets in the right
hemispace (R), (number of total targets per hemispace = 18).

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Faces and Emotions Modulate Spatial Neglect
Stimuli and procedure
Black lines (180 × 1 mm) were used as stimuli. Each line was
placed horizontally and centrally on a separate sheet of
paper. Black-and-white photographs of 8 different actors
taken from Ekman’s series (Ekman and Friesen, 1976)
(4 males; 60 × 40 mm) with either a neutral, happy, or angry
expression served as cues and could be present at the right or
left end of the line, or absent. When present, the cues were of
three different types: a picture of a neutral, happy or angry face.
The neutral faces provided an appropriate and extremely
conservative control condition because, like emotional faces,
they belong to the same stimulus category, have the same
personal identity (as the same actors presented with a neutral
expression were also shown with an emotional expression), and
share the same dimensions, elementary components and global
configuration. Overall there were seven possible stimulus
conditions: three different cue types on the left, three on the
right, and the no cue condition where only the lines were
present.
The midpoint of each line was aligned with the patient’s
mid-sagittal plane. The task was to mark the midpoint of the
line using the right hand. Before doing so, patients were
asked to pay attention to both sides of the line and to put a
mark under the cues, if any, whatever was depicted. Thus
emotional content in cues was completely irrelevant to the
task and could be ignored. Each patient bisected 20 lines per
condition for a total of 140 lines randomly presented and
divided into 4 subsequent blocks of 35 lines each.
Errors in line bisection for each patient and condition were
measured to the nearest millimeter. Errors to the right of the
objective midpoint were given a positive and those to the left
a negative value.

Results
Figure 2 reports the performances of patient FM (a) and of the
control group (b) as a function of the seven cue conditions.

Cueing Effect
Patient FM
In order to evaluate whether the cueing manipulation was
effective in FM, all three left cue conditions were collapsed
into a single left cue condition, and vice-versa for the right
cue conditions. An ANOVA was then performed on error
scores with the within-subjects factor of Cue Position (no cue
(NC), left cue (LC), and right cue (RC)).
There was a significant main effect of Cue Position
(F(2,38) = 146.54, p < .001). Post-hoc tests (Newman-Keuls
for all comparisons henceforth) revealed that the rightward
bias shown with no cue decreased in the LC condition and
increased in the RC condition (p < .0002 and p < .007,
respectively).
Control group
We performed an ANOVA on mean error scores for the control group with the same factors and levels considered for
FM. The main effect of Cue Position was statistically significant (F(2,6) = 24.36, p < .001). Post hoc tests revealed that
bisections were placed significantly to the left in the left cue
condition compared with no cue and right cue conditions (p <
.014 and p < .002, respectively). Similarly, right cues resulted
in increased rightward errors as compared to the no cue and
left cue conditions (p < .013).

Fig. 2. Mean error (mm) in the line bisection task for FM (a) and the Control Group (b) by cue position and cue type. Rightward errors are
coded as positive, leftward as negative. Error bars indicate standard deviation.

402
These results show that the cueing manipulation was effective in modulating bisection performance in patient FM, as
well as in the control group. Obviously, the absolute rightward error and effect size was much greater in the neglect
patient than in the control group.
Emotional effect
Patient FM
A 2 × 3 ANOVA was computed with the within-subjects factors of Cue Position (left vs. right) and Cue Type (neutral
(NF), happy (HF), and angry face (AF)). The emotional
effect was thus tackled by comparing the performance in the
NF condition with that in the emotional face conditions (i.e.,
HF and AF). The effect of Cue Position was significant
(F(1,19) = 412.7, p < .001), further indicating an efficient
cueing manipulation. The effect of Cue Type was not significant but the Cue Position X Cue Type interaction clearly was
(F(2,38) = 6.77, p < .003). Post-hoc tests on the interaction
showed that bisections with left HF and AF cues were placed
significantly further to the left by reference to the left NF
condition (p < .005 for both comparisons). The left HF and
AF conditions did not differ from each other (p > .5). There
was no significant difference among right cues (p > .25 for all
comparisons).
Control group
The ANOVA on mean errors showed only a significant effect
of Cue Position (F(1,3) = 57.89, p < .004), indicating a comparable influence of all left cues in shifting bisections leftward and of all right cues in increasing rightward bias.
Importantly, no specific effect due to the emotional value of
the cues was found.

Discussion
Prior studies testing neglect patients with the line bisection
task documented an influence of left cues in reducing the
rightward bias, and an enhancement of the rightward bisection error with unilateral right cues (Riddoch and Humphreys,
1983; Nichelli et al., 1989). The mechanisms responsible for
this cueing effect are, however, still unclear. The two major
theoretical accounts have proposed both an attentional and a perceptual explanation (Fischer, 2001). Attentional explanations
assume that cues call for attention, thereby increasing the
salience of the cued side. This modulation of spatial attention
‘pulls’ the patients’ bisection behavior to the cued side (Milner
et al., 1992; Olk and Harvey, 2002). Perceptual interpretations,
on the other hand, consider that cueing effects might best be
explained by the alteration of the perceptual point of balance
of the stimulus toward the cued side (Mattingley et al., 1993;
Fischer, 1994).
In the present study, we have addressed the issue of the mechanisms underlying cueing effects by varying the attentional

Tamietto et al.
salience of the cues while keeping their physical dimensions
constant. This cueing paradigm has not earlier been used with
neglect patients. Nor has a comparison between right braindamaged patients with and without neglect been performed
before. In keeping with previous studies, control patients
without neglect showed a weak bisection bias to the right in
the no cue condition, whereas the neglect patient FM revealed
a larger rightward bias in the same condition (Machado and
Rafal, 1999; Olk and Harvey, 2002). The cueing manipulation per se was also evident in both patient FM and the control group, with left cues reducing, and right cues increasing
the bisection bias.
More interestingly, the various cueing conditions affected
the subjectively perceived length of the lines in different
ways depending on the type of patients and on the side where
cues appeared. In control subjects with right hemisphere
lesions, the specific content of the cues did not affect line
bisection either with left of right cues. Indeed, the Cue Type
factor and the Cue Position X Cue Type interaction were both
nonsignificant. In patient FM, by contrast, left happy and
angry faces were more effective than left neutral faces in
reducing the rightward directional bias. Importantly, the
modulation of emotional faces on line bisection was confined
to the left (neglected) hemispace and occurred even though
the content of the cues was irrelevant to the task. This is
unlikely to be the result of some low-level perceptual differences among stimuli. Indeed, all stimuli shared the same
dimensions, and had the same elementary components and
global configuration. Our findings are also unlikely to be the
result of differences in the personal identity of the faces, as
the same actors presented with a neutral expression were also
shown with an emotional expression. Furthermore, FM
appeared to be hemianopic in the standard confrontation test
(see Table 1). Even though the assessment of primary visual
field deficits in neglect patients through clinical tests is not
conclusive, it could be argued that FM at least behaved as if
she had hemianopia. This suggests that at the very moment of
bisection (i.e., when the patient was certainly foveating the
tip of the pen), left cues were prevented from vision, thus rendering unlikely any influence related to possible low-level
perceptual factors.
The different influence of the left cues in a neglect patient
as a function of their emotional and attentional value, clearly
supports the idea that the cueing effect works through biasing
attention rather than by altering the perceptual point of
balance (at least in the contralesional hemispace). This view
is also in line with other studies that used invisible (Harvey
et al., 2000; Olk and Harvey, 2002) or symmetrical cues
(Jeerakathil and Kirk, 1994; Kashmere and Kirk, 1997).
Conversely, an interpretation based on the alteration of the
perceptual point of balance would predict a comparable influence of all unilateral left cues in reducing the rightward bias,
whatever their specific content, which was not the case.
Arguably, in the left (contralesional) hemispace of neglect
patients, where the systems for normal length perception and
cueing effects may have been damaged by right parietal

403

Faces and Emotions Modulate Spatial Neglect
lesions, the attentional manipulation becomes apparent.
Conversely, in the right (ipsilesional) hemispace of neglect
patients, and in patients without neglect where the attentional
system is relatively preserved, the attentional call due to the
salience of emotional faces may be overridden by perceptual
factors. An alternative, and less likely, interpretation might
be that the enhanced influence of left as compared to right
emotional cues indicates that cueing effects work differently,
depending on whether they are concomitant with lateralized
attentional deficits. An attentional mechanism for contralesional cues in neglect patients could thus be hypothesized,
whereas a perceptual mechanism could account for the influence of ipsilesional cues in neglect patients and for both left
and right cues in subjects with right hemisphere lesions
without neglect. This latter interpretation, however, is much
less parsimonious than the former and needs further empirical
support to be taken into consideration.
Prior behavioral findings have suggested that the distribution of spatial attention in patients with visual extinction and
spatial neglect may be influenced by emotional faces
(Vuilleumier and Schwartz, 2001). Here we show for the first
time in a line bisection task that this influence on spatial
attention has additional behavioral consequences in promoting
salience and access to action in the contralesional hemispace.
The privileged processing of emotional faces, even when
task-irrelevant, suggests that (a) the emotional content of the
faces can be encoded in the neglected hemispace, (b) the
results of such encoding can shift the attentional focus, and
(c) this modulation of spatial attention guides subsequent orienting behaviors and motor outputs to salient left-sided events.
However, within an attentional account of the emotional
cueing effect, the specific mechanisms through which facial
expressions increased the salience of the cued left side of the
line still remain unclear. Indeed, it has been shown that the
attentional call of emotional faces may directly modulate
early visual processing and peripheral stimulus detection
across the visual field (Morris et al., 1998; Vuilleumier and
Schwartz, 2001; Vuilleumier et al., 2004). Alternatively, it is
also possible that emotional cues exerted an influence on the
maintenance in the spatial working memory (SWM) of previously inspected locations, therefore rendering more salient
and/or efficient the remembering of the left side of the line.
This would be in keeping with recent studies showing that
non-lateralized SWM deficits are often associated with, and
can exacerbate, spatial neglect (Husain et al., 2001; Wojciulik
et al., 2001; Driver and Husain, 2002; Malhotra et al., 2004,
2005).
The involvement of specific limbic structures (amygdala,
cingulate, and orbitofrontal cortex) in processing emotional
information has been repeatedly demonstrated with different
techniques and in various neurological conditions (Adolphs,
2002). Interestingly, even in neglect patients, unattended and
unseen affective facial expressions underwent substantial
neural processing and activated the amygdala (Vuilleumier
et al., 2002). Thus such limbic activation is the most probable
candidate for the attentional enhancement due to emotional

stimuli observed here and, more specifically, suggests the
role of the amygdala in regulating cortical processing.
Indeed, the amygdala might be activated by information from
the contralesional hemispace through direct pathways from
the thalamus bypassing the primary visual cortex or via
ventral occipito-temporal pathway (de Gelder et al., 1999;
Morris et al., 1999; Morris et al., 2001). Then, the amygdala
might exert its modulatory role by direct projections to visual
areas (Vuilleumier et al., 2004), via reciprocal connections to
the anterior attentional network in the dorsolateral prefrontal
cortex (Pessoa et al., 2002), or through complex interactions
with other medial temporal structures (e.g., the hippocampus)
and prefrontal areas involved in memory functions (Peinadomanzano, 1990; McGaugh, 2000; Roozendaal et al., 2004).
This triple involvement of limbic structures in emotional processing, spatial attention, and memory might have given
more weight to emotional faces competing for attention and
action. In this context, it is worth noting that the foregoing
limbic areas were bilaterally intact in patient FM, who consistently performed in the normal range in the ESFT.
Overall, our findings support the neuro-functional model
of spatial attention put forth by Mesulam (1999; 2002) where
the salience of extrapersonal events encoded by limbic areas
is regarded as particularly influential on attentional shift. In
the model, spatial attention depends on a neural network
including mainly the posterior parietal, dorsolateral frontal,
and cingulated cortex. Although all these components are
collectively engaged in specifying whether an external event
will attract attention, the parietal cortex is more involved in
providing a sensory representation of the extrapersonal space,
the dorsolateral frontal cortex subserves exploratory motor
plans, and the cingulated and limbic components play a critical role in identifying the motivational relevance of extrapersonal events. Even though the role of limbic areas is the least
well understood, our results suggest that intact limbic and
frontal structures might still mediate attentional shift and
motor planning in spite of parietal damage and spatial
neglect.

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