This is the Accepted Manuscript of an article whose final and definitive form has been
published in Neurocase DOI:10.1080/13554794.2014.974620
http://www.tandfonline.com/doi/abs/10.1080/13554794.2014.974620

Peculiar body representation alterations in hemineglect: a case report
Authors: Antonella Di Vita a, Liana Palermo a,b, Laura Piccardi a c, Cecilia Guariglia a d

Affiliations:
a

I.R.C.C.S. Fondazione Santa Lucia, Rome, Italy

b

School of Life & Health Sciences, Aston University, Birmingham UK

c

Dipartimento di Medicina Clinica, Sanità Pubblica, Scienza della Vita e dell’Ambiente,

Università degli Studi di L’Aquila, L’Aquila, Italy
d

Dipartimento Psicologia 39, Sapienza Università di Roma, Rome, Italy

Running Head: Body schema deficit and delusional ideas: a case

Corresponding author:
Dr. Antonella Di Vita, Psy.D.
Neuropsychology Unit
I.R.C.C.S. Fondazione Santa Lucia
Via Ardeatina, 306
00179 Rome, Italy
mail: antonella.divita@uniroma1.it
Tel. +39(0)651501117
Fax +39(0)651501366

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2

Abstract
We report the case of FP affected by personal and extrapersonal neglect and a body
representation deficit characterized by delusional ideas. When FP performed the human
figure, he placed body parts to the left, despite his extrapersonal neglect. Differently, when
he performed the car figure he placed all parts to the right, in line with his deficit.
Comparing FP with a small patient group with the same clinical features without delusional
ideas about body emerged that he was the only one to suffer from a specific body
representation deficit characterized by a lack of body ownership sense.

Keywords: personal neglect, body representation, body ownership, body schema,
anosognosia

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Introduction
Understanding the mechanisms through which the brain represents the body is one of the
most challenging issues of neuroscience in the recent years. Our body is, in fact, a special
subject of investigation since the ways in which we deal with it are numerous: touch, vision,
proprioception, motor behaviour, semantic comprehension, emotions and feelings. So, we
receive more information on our body than on any other objects, and unlike other physical
objects, we perceive it from within (de Vignemount, 2011).
The different experiences through that we deal with our body explain the wide ranges of
body representation alterations following brain injury (for a classification see de
Vignemount et al., 2010). Among these disorders, clinical neuropsychology distinguishes
between body parts localization (personal neglect; autotopagnosia, etc…) and body
awareness (somatoparaphrenia; supernumerary limbs syndrome). Concerning, in particular,
personal neglect there is not agreement about its nature as body mental representation
deficit. Coslett (1998) showed, for example, that unilateral neglect can be associated with a
body schema deficit. Using a task similar to that used by Parson (1994), which required
judging whether the presented image of a hand was a left or a right hand, Coslett found that
only neglect patients failed to correctly identify the drawings of the left hand.
Guariglia and Antonucci (1992) described a patient who suffered from pure personal neglect
who could not correctly locate different ipsilesional and contralesional body parts in
reconstructing the image of the body or the face.
Moreover, Baas et al. (2011) compared the performance of patients with and without
personal neglect in mental rotation tasks of hands and objects to assess the cognitive
mechanisms underlying personal neglect. Their results showed that patients with personal
neglect make more errors with left stimuli regardless of whether the stimulus is a hand or an
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object. Furthermore, they found that errors in judging left hands predict the presence of
personal neglect, whereas other variables, such as the presence of sensory or motor deficits,
were not predictive. Although results of the mental rotation tasks showed that personal
neglect could not be attributed only to a deficit in the representation of the body, according
to the authors, results of the regression analysis, suggested that the deficit in the
representation of the contralesional body was the main mechanism underlying personal
neglect.
As mentioned above we deal with our body in different way but what is unique and differs
our body from other objects is its ownership, in other words, “the feeling that my body
belongs to me, and is ever present in my mental life” (Tsakiris, Hesse, Boy, Haggard, &
Fink, 2007), the body awareness deficits are, in fact, considered a part from body
localization deficits in the clinical neuropsychology (see above). The sense of body
ownership may be destroyed after a brain damage, this causes different delusional beliefs
concerning the body which are usually reported in literature with the term of
"somatoparaphrenia". This neurologically deficit is originally defined by Gerstmann (1942)
as characterized by ‘illusions or distortions concerning the perception of, and confabulations
or delusion referring to the affected limbs or side’. Moreover the author distinguished
somatoparaphrenia from autosomatamnesia and autosomatagnosia, respectively the absence
of memory and consciousness of the affected body parts. Over time many different
definitions have been proposed (see Vallar & Ronchi 2009 for a review) due to the fact that
somatoparaphrenia is usually associated with other symptoms (i.e. neglect, anosognosia,
somatosensory deficits etc.) and is fluctuating over time (Vallar & Ronchi 2009). Recently,
Vallar & Ronchi (2009) suggested that defective multisensory integration together with a
disorder in the spatial representation of the body is the mechanism at the basis of
somatoparaphrenia. Also the neurocognitive model developed by Tsakiris (2010) on the
basis of data on rubber hand illusion, suggests that body-ownership originates from the
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interaction between current multisensory input and internal models of the body.
In the present paper we described a patient with a modification at the level of the visuospatial body map that seems related to a lack of body ownership sense and a personal
neglect as a consequence of a large lesion in the right hemisphere, involving also the insularlenticular region.

Case History
FP is a 63-year-old right-handed retired man with 5 years of education who had a vascular
accident that resulted in left hemiplegia. He was admitted to the IRCCS Fondazione Santa
Lucia (Rome, Italy) for inpatient rehabilitation treatment about ten days after onset of the
cerebro-vascular accident (CVA).
The neurological exam at admission showed psychomotor slowing, a tendency towards
drowsiness, gaze deflected to the right, dysarthria, facio-brachio-crural left hemiplegia, left
limb hypotonia and poor control of the torso in a sitting position.
Visual field assessment performed about one month after the CVA also showed a probable
left-sided deficit and a severe visual acuity deficit in the right eye.
Approximately one month after the CVA, an MRI exam was performed at the Neuroimaging
Laboratory of the IRCCS Fondazione Santa Lucia. The exam was carried out in a 3.0 T
scanner (Allegra, Siemens Medical Solutions, Erlangen, Germany). The images showed the
presence of a large area of altered intensity, hyperintense on T2 and hypointense on T1,
located in the right cortico-subcortical fronto-temporo-parietal and right insular cortex.
Moderate reduction in amplitude of the signal in the subarachnoid spaces adjacent to the
mantle and a slight compressive effect on the ipsilateral supratentorial ventricular system,
without midline shift, were observed (see Figure 1)
---insert Figure 1 about here--About twenty days after onset of the CVA, FP underwent an extensive neuropsychological
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evaluation (see Table 1 for details) that revealed the presence of personal and peripersonal
neglect.
---insert table 1 about here--The patient was unable to describe his clinical conditions and was also unaware of his motor
deficits (anosognosia for the motor deficit = 2; Bisiach et al.’s scale: 1986); he
spontaneously complained of a generalized state of fear and reported difficulty in speech
(dysarthria) and in maintaining attention only if specifically questioned.
FP was also unaware of his explorative deficit in both personal and extrapersonal space.
His wife reported that he had expressed delusional ideas about the left side of his body, i.e.,
he asked his wife to check whether his arm had been left in the gym because it was no
longer there. Following Vallar and Ronchi’s (2009) classification, his behaviour
corresponded to “delusional beliefs of dis-ownership of the affected body parts”. His
delusional ideas and anosognosia for neglect and motor deficits fluctuated (this is common
in these disease that usually lasts for days or weeks, in fact to our knowledge only three
cases of chronic somatoparaphrenia were described, see Cogliano, Crisci, Conson, Grossi &
Trojano, 2012 and Nightingale, 1982). In general, FP felt that his arm was missing; when
the examiner pointed out that FP's arm was attached to his shoulder, he stated that it was not
his arm. It was not possible to examine in a standard way the characteristic of FP's
delusional beliefs since, as mentioned above, these fluctuated over the time.
To more thoroughly analyse this disorder, FP was submitted to an extensive
neuropsychological evaluation. The study was approved by the local Ethics Committee in
accordance with the Helsinki Declaration and the patient provided his written consent to
participate in the neuropsychological investigation.
The patient’s visual-explorative abilities were further investigated with a functional
evaluation to determine whether he showed any difference between peri-personal and extrapersonal space and with structured tests to assess whether he also had a deficit in the
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imagery domain (representational neglect).
The functional evaluation consisted of a visual-spatial scanning task (TSVs; Judica, Galati,
& Zoccolotti, 1996) in which the patient had to respond as quickly as possible to visual
stimuli presented on a wide screen (surface stimulation at 80°x 45°); 48 stimuli were
presented in random positions. Results showed that FP's exploration of extrapersonal space
was strongly asymmetric because he missed most of the contralesional stimuli. The presence
of asymmetries in generating an image from long-term memory was assessed by asking the
patient to perform the O'clock test (Grossi, Modaferri, Pelosi, & Trojano, 1989) and the
Familiar Square Description test (Guariglia, Palermo, Piccardi, Iaria, & Incoccia, 2013). The
familiar squares chosen for the test were well-known to FP before the illness onset and they
were comparable for familiarity and number of details. FP’s performance on the O'clock test
was well within the normal range (LQ= -12, Cut-off=/> -20; Guariglia et al., 2013). Also, on
the Familiar Square Description test he made a very detailed description (without any
asymmetry) of both left-sided and right-sided elements (Guariglia et al., 2013). Note,
however, that FP was unable to maintain the perspective given by the examiner and he used
the previously described single elements as a point of reference in recalling the location of
the others (e.g. “at the left of the church there are some arches, at the left of the arches is the
police station, [...]” etc…). Based on these results, FP showed no signs of representational
neglect, but seemed to be affected by a more general deficit in imagining something with
respect to his body (i.e. egocentric perspective).
In summary, FP showed severe left unilateral neglect in personal, peri-personal and
extrapersonal space but not in the imaginative domain. He also suffered from pervasive
somatoparaphrenia and anosognosia. Since, FP showed body representation deficits we
submitted him to an extensive evaluation about body representation to better understand the
nature of his disorders that if not rehabilitated could compromise his motor recovery.

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Body representation assessment
Several tests were performed to assess the involvement of different types of body
representation in personal neglect.
Human figure drawing
When FP was asked to draw a human figure, he drew a man in uniform with his head turned
to the left (see Figure 2). Although the drawing contains all body parts and their proportions
are generally respected, there is evidence of an asymmetry in the height of the shoulders and
the length of the lower limbs.
----insert Figure 2 about here---

Localisation of body parts
The ability to locate body parts was assessed by means of a modified version of Semenza
and Goodglass’s Test (Semenza & Goodglass, 1985). In this test, patients are required to
point to 26 parts of the body, first on themselves and then on the examiner; body parts are
presented randomly and are non-lateralized (i.e., the nose), left-sided and right-sided (i.e.,
the left eye, the right eye). FP performed flawlessly on both his own and the examiner’s
body.
Body representation test
The visuo-spatial map of the body was assessed with the “Frontal body-evocation” (FBE)
“Frontal face-evocation” (FFE) and “Lateral face-evocation” (LFE) subtests of the Body
Representation test (Daurat-Hmeljak, Stambak, & Berges, 1978). Although this test was
developed for use with children, it has been used to study impairments of body
representation in brain-damaged patients (Canzano, Piccardi, Bureca, & Guariglia, 2011;
Guariglia & Antonucci, 1992; Guariglia, Piccardi, Puglisi Allegra, & Traballesi, 2002;
Marangolo, Piccardi, Rinaldi, 2003). The test materials include a small plastic board on
which one reference part (the head for FBE, the contour of the face for FFE, and hair for
9

LFE) is depicted, and several tiles that represent body parts. Participants are presented with
one tile at time and their task is to name the body part depicted on the tile before putting it
on the board. Before presenting a new tile, the position of the previous tile is recorded on an
overlapping grid and the tile is removed. Moreover, for the LFE subtest the subject has to
choose among different views of the same body part before putting the tile on the table; for
example, the nose is presented in frontal, lateral right and lateral left views. Given that the
original test proposes only the right profile for the LFE subtest, an analogous version of the
left profile was created to determine whether the patient had any asymmetries due to the
presence of personal neglect.
FP’s results on each sub-test for both recognition (naming) and localization of the different
body parts are presented in Table 2.
----insert table 2 about here--A descriptive analysis of the patient’s performance showed that when he performed the
subtest which evaluated representation of the whole body (FBE) FP put all the body parts on
the left side of the board despite his severe left neglect (see Figure 3). This amazing
behaviour was observed only on the FBE subtest, not on the FFE or in the LFE (see Figure
4).
---insert Figure 3 about here-----insert Figure 4 about here---

The presence of a deficit in body representation was confirmed not only by the localization
errors FP made in all the sub-tests, but also by his choice errors on the LFE subtest. For
example, FP often chose frontal view parts instead of lateral ones, right parts instead of left
ones, and left parts instead of right ones.
Since performance of the Body Representation test (Daurat-Hmeljak et al., 1978) can be
affected by the presence of visual-constructive deficits, constructional apraxia was assessed
10

using copy of the Rey Complex Figure (Carlesimo et al., 2002) and the Constructional
Apraxia test (Spinnler & Tognoni, 1987).
On both tests, FP’s performance was clearly affected by the presence of neglect; that is, he
omitted the left-sided parts of the models and under-utilized the left side of the sheet of
paper. The presence of neglect emerged also in the strategies used to reproduce the models
that strongly disadvantaged his performance. Taking into account his exploratory deficit, he
performed in the normal range (raw score: 8/14, 14 standard score=1) on the Constructional
Apraxia test (Spinnler & Tognoni, 1987) and defectively on the copy of Rey’s Complex
Figure (raw score: 9/36, standard score=0; Carlesimo et al., 2002).
To evaluate the presence of general deficits in selecting and localizing parts of noncorporeal objects, we also administered the Car test (Guariglia et al., 2002), which was
developed to compare performance on the Body Representation test (Daurat-Hmeljak et al.,
1978) with performance on a non-body object that had well-defined right and left sides and
involved procedures and materials similar to those of Daurat-Hmeljak et al.’s test. In this
test, FP detected and correctly named 5/12 parts of the car and correctly placed 4/12 parts.
Errors consisted mostly of mis-locations of the parts. In fact, consistently with his neglect
for peri-personal and extrapersonal space, FP placed the parts mostly in the right space (see
Figure 5).
---insert Figure 5 about here--A comparison of the patient’s performance on the Body Representation Test and the Car
Test showed that FP tended to use only half of the plastic board to locate single parts but,
very surprisingly, used opposite sides for the two tests; that is, coherently with the presence
of left hemineglect in peri-personal and extra-personal space, FP used only the most rightsided part of the board to locate parts of the non-corporeal objects in the Car test, but used
only the most left-sided part of the board when he placed body parts in the FBE sub-test (see
Figure 3). Such incoherent use of just half of the board depending on the nature of the
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stimulus (body/non-body) has never been reported before. Therefore, we compared FP’s
performance on the FBE subtest with the performance of 13 healthy control participants (C)
and 5 right brain-damaged patients (BDP) suffering from both personal and peripersonal
neglect (see Table 3 for neglect assessment details) but not by somatoparaphrenia and/or
representational neglect.
---insert Table 3 about here--In particular, using BTD_Cov.exe software (Crawford, Garthwaite, & Ryan, 2011), the
number of parts properly recognized (recognition score-R), parts properly positioned
(localization score-L) and left body parts placed to the right (left-right inversion error scoreLRI error) by FP were compared to those of C and BDP. Since only C (not BDP) were
matched for age and education, these factors were used as covariates (Table 4 shows the
means and standard deviations of the two groups and FP’s performance).
---insert table 4 about here--Results show that FP’s recognition performance differed significantly from the C group’s (p
= 0.03) but not the BDP group’s (p = 0.46) performance.
The same pattern of results emerged when the number of parts correctly positioned was
compared: also in this case, FP scored lower than the C group (p= 0.03) but not the BDP
group (p = 0.44). Instead, FP’s performance differed significantly from that of both C (p=
0.00) and BDP (p= 0.026) groups for number of left-right inversions (LRI).
In summary, the patient’s performance was significantly different from the C group’s
performance on all indices considered, but differed significantly from the BDP group’s
performance only in the number of LRI errors, because in the latter group LRI errors were
infrequent.
Note that a perusal of individual patients’ performances shows that no patients in the BDP
group performed the test by locating parts only on the left half of the board.

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Lesion analysis
Subtraction Analysis
In order to identify the anatomical structures damaged in FP but not in the BDP group an
exploratory Subtraction Analysis was conducted.
The boundaries of the lesions were delineated directly on the Modified Driven Equilibrium
Fourier Transform (MDEFT) for every single axial slice using MRIcron (Rorden, Karnath,
& Bonilha, 2007; www.Mricro.com/mricron) software. For each lesion, the corresponding
mask was created. The volume of the lesion and the full set of MDEFT sequences were
simultaneously normalised according to the protocol of Brett, Leff, Rorden, & Ashburner
(2001) by using SPM8 (Welcome Department of Cognitive Neurology, London, UK)
software implemented in Matlab (The MathWorks Inc., Natick, MA, USA). Then, using
MRIcron software (Rorden et al., 2007) a lesion overlap image of three patients in the BDP
(two patients of the BDP group did not agree to undergo the MRI exam) group was created.
FP’s lesion was overlapped with that of a patient with personal neglect (Pt6) who commits
only an LRI error. It should be noted that Pt6 was not considered in the previous analyses
because the patient was affected only by personal neglect.
The results presented in Figure 6 indicate the areas that are damaged in patients who made
LRI errors in the FBE sub-test; these include the right insula, precentral gyrus and superior,
middle and inferior frontal gyrus. The lesions also include the white matter surrounding the
above-mentioned structures and the superior corona radiata.
---insert Figure 6 about here---

Discussion
The case of FP provides new insights about the complex body representation process.
Different hypotheses can be advanced to explain the patient’s peculiar performance on the
neuropsychological tests. First, it can be hypothesized that to carry out the task of locating
13

body parts on Daurat-Hmeljak et al’s test FP had to access the mental representation of his
own body which, due to the presence of personal neglect, is distorted. Due to this distorted
representation, FP is unable to correctly locate left-sided body parts but is still able to locate
right-sided ones. Thus, when required to locate the right arm on the board, FP correctly put
it on the left side; but when required to locate the left arm, his distorted body representation
did not allow FP to put it on the right half of the board, corresponding to the left side of the
body.
The left side of space is, in fact, the right side of the body because the figure is presented in
a frontal view. This “mirroring” error in locating body parts, but not non-body parts, cannot
be attributed to the mere presence of personal neglect. As found also in previous studies in
which the same FBE task was used (Guariglia & Antonucci, 1992; Piccardi, Nico &
Guariglia poster session, 2002), BDP patients showed no asymmetry on the FBE task but
made errors in localizing body parts on both sides of space. These data support the
hypothesis that personal neglect is a disorder of the mental representation of the body (Baas
et al., 2011; Palermo, Di Vita, Traballesi, & Guariglia, 2014). Nevertheless, FP’s
performance was peculiar and rather different from that of previous patients affected by the
same body representation deficit who were never reported to neglect the right side of the
board in the FBE task. The absence of other forms of neglect could account for the
performance differences between EDS (Guariglia & Antonucci, 1992) and FP. Indeed, it
must be considered that the patient described by Guariglia and Antonucci (1992) and the
patients reported by Piccardi Nico & Guariglia (poster session, 2002) suffered from pure
personal neglect, whereas FP was affected by both personal and extrapersonal neglect.
However, as all of the BDP patients recruited for the present study were affected by both
personal and extrapersonal neglect, the possibility that they used one half of the board for
body representation (FBE test) and the other half for object representation (Car Test) has to
be excluded, because this peculiar behaviour was not observed in any patient except FP.
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Furthermore, analysis of the errors excludes the possibility of attributing FP’s inversion
errors exclusively to the co-presence of extrapersonal neglect. Indeed, localization errors
were observed in both BDP and FP, with the same frequency as that reported in previous
studies; it should be noted that FP’s localization performance did not differ from that of
BDP (Guariglia & Antonucci, 1992; Piccardi Nico & Guariglia (poster session, 2002). The
only difference was the high number of inversion errors made by FP, because this type of
error is infrequent in BDP and never described in previous studies (Guariglia & Antonucci,
1992; Piccardi Piccardi Nico & Guariglia (poster session, 2002).
Apart from FP’s many inversion errors, what makes him different from the patient described
by Guariglia and Antonucci (1992), the patients reported by Piccardi Nico & Guariglia
(poster session, 2002) and the patients in the BDP group is the presence of a delusional idea
about the body.
The lack of ownership of the left side of the body, which characterized FP, could explain his
performance on the Body Representation test. When the task required an embodiment (“the
sense of being localized within one’s physical body” – Arzy, Thut, Mohr, Michel, & Blanke,
2006), similar to the FBE sub-test, FP showed a half body representation lacking of the left
body parts placed on the right of the space.
The presence of an altered visuo-spatial body representation could also explain the patient’s
difficulty in maintaining his egocentric frame of reference during the description of the
familiar squares. Indeed, an embodiment is required to perform this task. In order to build up
an egocentric representation of the square and properly describe it, the subject has to
imagine his own body with respect to the environment. As FP was unable to represent his
own body, he could not use this representation as the reference point to mentally explore the
represented square and to describe the elements in the square and had to use the spatial
relations among the elements.
In the light of this interpretation, FP’s good performance on the modified version of
15

Semenza and Goodglass’s test deserves further explanation. His performance indicates that
he was able to localise body parts on both his body and that of the examiner. Being able to
point to body parts might depend on an embodiment process (e.g., I can localize your right
eye because of my embodiment in you). Indeed, Auclair, Noulhiane, Raibaut and Amarenco
(2009) interpreted their case of heterotopoagnosia as an embodiment deficit. In their patient,
the impairment in converting the intrinsic spatial coding of the body parts into extrinsic ones
was revealed by difficulty in pointing to body parts both on the examiner and a schematic
body representation. Nevertheless, the same task can be performed by relying on other types
of body representation, such as semantic representation of the body (e.g., having semantic
knowledge about the right eye I am able to recognize it and to point to it even if I have no
idea about its actual location). Indeed, FP did not lose his semantic knowledge of the body.
He never failed to recognize single body parts. Furthermore, the modified version of
Semenza and Goodglass’s Test has a strong categorical nature that helped FP use his
preserved body knowledge. In fact, pointing to single body parts by relying on semantic
processing does not necessarily require knowledge about the mutual position of different
body parts; thus, people are able to recognize a right ear or a left knee even if they are
presented in isolation or drawn in the wrong place (which happens when we look at a cubist
portrait).
In the literature, other cases of correct pointing to body parts that were the object of
delusional ideas were reported by Meador, Loring, Feinberg, Lee, and Nichols (2000). In
their study, the presence of asomatoagnosia (“i.e., the inability to recognize the affected limb
as one’s own”) was not related to non-verbal knowledge (pointing) to the location of a
paralyzed limb; in fact, patients who correctly pointed to the paralyzed limb were affected
by asomatoagnosia.
Theoretical frameworks of body representation, like the triadic taxonomy of body
representation (Schwoebel & Coslett, 2005; Sirigu, Grafman, Bressler, & Sunderland, 1991)
16

considers the existence of a triadic representation of the body: i) the “body schema” a
sensory-motor representation of the body; ii) the "semantics of the body", a conceptual and
linguistic representation, and iii) the "structural description of the body," that is a visuospatial map of the different body parts. According to this FP shows a mental body
representation deficit at the level of the visuo-spatial body map. This deficit seems to
explain both the presence of personal neglect and the lack of ownership of his left limbs. In
this view, the FP’s performance on the FBE sub-test confirms the hypothesis that
somatoparafrenic delusion has a spatial component (Vallar & Ronchi, 2009) which is framed
at the visual-spatial body map level.
Results of the lesion analysis also confirm the link between spatial body representation and
body ownership. Although it should be considered that the analyses were conducted in a
small number of patients, the results of the subtraction analysis showed the involvement of
brain areas (e.g., the insula and frontal lobe) which are considered part of the network that
processes the sense of body ownership. In particular, the insula is considered to constitute
the basis for the subjective experience of the body (Tsakiris, 2010) because of its role in
elaborating visceral, somatosensory and vestibular information (Augustine, 1996; Craig,
2009). Even if the involvement of the insula in the formation of the sense of limbs
ownership emerges from both lesion (Baier & Karnath, 2008) and PET (Tsakiris et al.,
2007) studies, and from the application of the rubber hand illusion paradigm (Moseley et al.,
2008; Ehrsson, Wiech, Weiskopf, Dolan, Passingham, 2007), the insula contribution has not
yet been definitely determined. Some authors (i.e., Gondola et al., 2012) consider that the
insula damage is associated with neglect that is almost invariably present together with
somatoparaphrenia.
The insula involvement here reported is in line with those studies that consider the insula
important for the body representation due to its contribution in the processing of
interoceptive information (Craig, 2009; Grossi, Di Vita, Palermo, Sabatini, Trojano,
17

Guariglia, 2014). As Berlucchi & Aglioti (2010) noted, this information become important
not only for the sensations per se but also because these sensations evoke actions directed to
the body (i.e., scratch the itchy).
The importance of other information besides the proprioceptive one’s in the genesis of the
body ownership sense is shown also by the dissociation between sense of disownership and
undamaged capacities in judging the position sense described by Cogliano et al. (2012) in a
patient with chronic somatoparaphrenia.
Moreover, with regard to the frontal lobe, results show involvement of the premotor cortex,
the site for the integration of multisensory information, that interact to build up a consistent
representation of the body parts (Gandola et al., 2012). In fact, neuroimaging studies
(Ehrsson, Spence, & Passingham, 2004; Tsakiris et al., 2007) show activation of the
premotor cortex during the rubber hand illusion.
In summary, we hypothesise that a crucial role in the visual spatial body map is played by
the integration of information conveyed by the insula with other sensory-motor information
coming from the body, which is then integrated in the frontal area representing the seat of
other bodily representations. Damage in this network results in a lack of this integration and
affects the ability to represent the body as a whole. Thus, the body representation becomes
that of a half body because the patient is unable to update his body representation with
information coming from the right side of the body and the visually perceived contralesional
body parts do not elicit any sense of ownership and thus produce the delusional behaviour.

Acknowledgements
This study was supported by funding from MIUR to C.G. (PRIN 2010-2011; nr
2010ENPRYE_004).
The funders had no role in the study design, data collection and analysis, decision to publish
18

or preparation of the manuscript.

19

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26

Figure legends:
Figure 1. Sagittal (a) and axial (b) section of FP’s MR

27

Figure 2. Human Figure drawn by FP

28

Figure 3. Performance on the Frontal body-evocation sub-test of FP (a) and that of a patient of the
BDP group (b)

29

Figure 4. FP’s performance on the Frontal face-evocation sub-test (a), Lateral face-evocation
(right) sub-test (b) and Lateral face-evocation (left) sub-test (c) of the Body Representation Test.

30

Figure 5. Car Test

31

Figure 6. Subtraction Analysis. The figure shows the probability map resulting from subtraction
of the probability map of the patients who made LRI-errors from the probability map of patients
who did not make LRI-errors. The range of colours from 30 indicates areas with the greatest
probability of being damaged in patients who make LRI-errors.

32

Table1 Neuropsychological Assessment

TEST

FP score

SS*

Time Orientation (Spinnler & Tognoni, 1987)

96/100

Space Orientation (city/hospital/hospital name)

+++

Verbal Judgment (Spinnler & Tognoni, 1987)

46/60

3

Episodic memory (Novelli et al., 1986)

13,5/28

4

Digit Span ( Orsini et al.,1987)

6/9

4

WAIS Digit Span Backward (Orsini, 2003)

3

7

Standard Battery for the Evaluation of Hemineglect** (Pizzamiglio et al.,
1989)
Letter Cancellation test

SN 0/53
DX 2/51

Line Cancellation test

SN 0/11
DX 1/10

Wundt-Jastrow Area Illusion test

SN 8/20
DX 0/20

Sentence Reading test
Personal Neglect *** (Zoccolotti et al.,1991)

0/6
9/9

Performances below the cut-off are indicated in bold
*SS = standard score from 1 to 4 in the normal range; 0 is pathological
**Patients who scored below the cut-off on at least two of these four tests were considered to have visuo-spatial neglect (Pizzamiglio et al.,
1989). Letter Cancellation test: cut-off is a difference of 4 (or more) omissions between the right and the left side; Line Cancellation: cut-off is >2
omissions on the left side; Wundt-Jastrow Area Illusion Test: cut-off is a difference >2 between unexpected answers (i.e., responses in the
direction opposite to the illusory effect observed in healthy individuals) given for left-oriented minus right-oriented stimuli; Sentence Reading
Test: Hits are the number of correctly read sentences. The cut-off is one or more sentences incompletely read on the left side.
*** The presence of personal neglect was revealed by means of a standardized test (Zoccolotti et al., 1991) that required the use of three
objects(eyeglasses, a razor or powder and a comb) in the body space. For each object, the examiner assigned a score based on the asymmetry in
performance of the patient in the left and right space (0 = no asymmetry, 3 = maximal asymmetry). Cut-off  2

33

Table 2 FP’s performance on the Body Representation sub-tests
SUB-TEST

FP score

Frontal body-evocation
Recognition

6/9

Localization

2/9

Recognition

11/12

Localization

2/12

Frontal face-evocation

Lateral face-evocation (right)
Face part choice

1/6

Recognition

6/6

Localization

0/6

Lateral face-evocation (left)
Face part choice

5/6

Recognition

4/6

Localization

1/6

34

Table 3 Neglect Assessment in the BDP group and Pt6

Participants

Letter Cancellation

Pt1
Pt2
Pt3
Pt4
Pt5
Pt6

Personal
Neglect***
(max 9)

Standard Battery for the Evaluation of Hemineglect**

Left
(max 53)
4
9
19
10
49
47

Right
(max 51)
36
13
44
27
41
48

Line Cancellation
Left
(max 11)
11
0
11
4
11
11

Right
(max 10)
10
10
10
7
10
10

Wund-Jastrow illusion
test
Left
Right
(max 20)
(max 20)
6
0
8
4
0
0
15
4
3
0
1
0

Sentence
Reading test
(max6)

0
1
5
3
3
6

** The presence of peripersonal neglect was revealed by means of the Standard Battery for the Evaluation of Hemineglect
(Pizzamiglio et al., 1989). Patients who scored below the cut-off on at least two of these four tests were considered to have visuospatial neglect (Pizzamiglio et al., 1989). Letter Cancellation test: cut-off is a difference of 4 (or more) omissions between the
right and the left side; Line Cancellation: cut-off is >2 omissions on the left side; Wundt-Jastrow Area Illusion Test: cut-off is a
difference >2 between unexpected answers (i.e., responses in the direction opposite to the illusory effect observed in healthy
individuals) given for left-oriented minus right-oriented stimuli; Sentence Reading Test: Hits are the number of correctly read
sentences. The cut-off is one or more sentences read incompletely on the left side.
*** The presence of personal neglect was revealed by means of a standardized test (Zoccolotti et al., 1991) that required the use
of three objects (eyeglasses, a razor or powder and a comb) in the body space. For each object, the examiner assigned a score
based on the asymmetry in performance of the patient in the left and right space (0 = no asymmetry, 3 = maximum asymmetry).

35

7
2
4
4
4
4

Table 4 Means and standard deviations of recognition score (R), localization score (L) and leftright inversion error score (LRI-error) in healthy control participants group (C) and braindamaged patients (BDP) group
R
6/9

L
2/9

LRI-error

mean

8.53

6.23

0.7

s.d.

0.96

1.69

0.2

mean

6.4

2.6

0.4

s.d.

1.67

2.52

0.5

FP’s score

4/4

C

BDP

36