A Behavioral Approach to Treatment and Assessment of People with Disorders of Consciousness: The Response-contingent Stimulation Strategy.

Response-contingent stimulation is a behavioral strategy used to improve the situation of patients with disorders of consciousness. Such strategy involves the presentation of brief periods (e.g., 10 to 15 s) of stimulation considered preferred by the patients, contingent on (immediately after) the emission of specific patients' responses. The aim is to help the patients learn the link between their responding and the preferred stimulation and thus learn to use their responding to access the stimulation in a self-determined/independent manner. Achieving these goals is considered important for the patients' recovery process and thus the response-contingent stimulation strategy that promotes such an achievement can be considered a valuable treatment approach. The same strategy combined with the use of periods of non-contingent stimulation (i.e., stimulation delivered independent of responding) may also serve as an assessment supplement with patients with apparent unresponsive wakefulness. The patients' increase in responding during the response-contingent stimulation and decline in responding during the non-contingent stimulation could be taken as a sign of discrimination between conditions, and possibly a sign of awareness of the immediate environmental situation, compatible with a diagnosis of minimally conscious state. This paper analyzes a number of studies aimed at using the response-contingent stimulation as a treatment strategy and a number of studies aimed at combining response-contingent stimulation with non-contingent stimulation for treatment and assessment purposes. The results of the studies are discussed in terms of the effectiveness, accessibility and affordability of the strategy. The need for new research (i.e., replication studies) is also pointed out.

Effects of stimulus-related variables on mental states recognition in Huntington's disease.

BACKGROUND: Cognitive abnormalities in Huntington's Disease (HD) can involve the specific impairment of the social perspective taking as well as difficulties in recognizing others' mental state many years before the onset of motor symptoms. AIMS: At the scope of assessing how the difficulties in mental state recognition might be an HD early sign before motor symptoms appear, our study was aimed to investigate how the recognition of others' mental states in HD subjects is moderated by different stimulus related features (gender, difficulty (low, medium, high), and valence (positive, negative, neutral) of the mental states that are to be recognized). METHODS: Subjects with premanifest (n = 20) and manifest (n = 40) HD performed the revised 'Reading the Mind in the Eyes Test' and were compared with age-matched healthy controls (HC, 40 subjects per cohort). RESULTS: Our results highlight an early impairment in mental state recognition preceding manifest HD symptoms and a deterioration of these abilities with HD progression. Moreover, we found in HD premanifest subjects an impairment concerning the recognition of negative and neutral mental states, as well as of mental states with moderate recognition difficulty. Finally, we found that participant gender did not influence the performance in recognizing others' mental states, while all participants recognized mental states displayed by females more accurately than those displayed by males. CONCLUSIONS: We conclude that difficulties in the recognition of complex mental states can be considered as an early sign of HD, before evident behavioral manifestations, and peculiar features of the stimulus influence it.

The representation of conceptual knowledge: visual, auditory, and olfactory imagery compared with semantic processing.

Two experiments comparing imaginative processing in different modalities and semantic processing were carried out to investigate the issue of whether conceptual knowledge can be represented in different format. Participants were asked to judge the similarity between visual images, auditory images, and olfactory images in the imaginative block, if two items belonged to the same category in the semantic block. Items were verbally cued in both experiments. The degree of similarity between the imaginative and semantic items was changed across experiments. Experiment 1 showed that the semantic processing was faster than the visual and the auditory imaginative processing, whereas no differentiation was possible between the semantic processing and the olfactory imaginative processing. Experiment 2 revealed that only the visual imaginative processing could be differentiated from the semantic processing in terms of accuracy. These results showed that the visual and auditory imaginative processing can be differentiated from the semantic processing, although both visual and auditory images strongly rely on semantic representations. On the contrary, no differentiation is possible within the olfactory domain. Results are discussed in the frame of the imagery debate.

The relationship between 'theory of mind' and attachment-related anxiety and avoidance in Italian adolescents.

This study examined the relationship between 'theory of mind' and attachment-related anxiety and avoidance in adolescence. The "Reading the Mind in the Eyes" test and the "Experiences in Close Relationships - Relationship Structures" questionnaires were administered to 402 14-19 year-old adolescents. Contrary to expectations, anxiety but not avoidance with mother was associated with less accurate mindreading, and this effect was stronger in younger than in older adolescents. Results might be explained in terms of the inconsistency of caregiver behavior that is supposed to cause anxious strategies, and thus illustrate the need to consider not only the effects, but also the causes of different types of insecure strategies.

Microswitch technology and contingent stimulation to promote adaptive engagement in persons with minimally conscious state: a case evaluation.

This study assessed whether a post-coma woman functioning at the lower end of the minimally conscious state would (a) develop adaptive responding through the use of microswitch technology and contingent stimulation, (b) consolidate and maintain her responding over time, and (c) show evidence of response-consequences awareness (learning and discrimination). The study involved an ABABB1CB1 sequence in which the A represented baseline phases, the B and B1 intervention phases, and the C a control phase with continuous stimulation. Results indicated that the woman developed adaptive responding and consolidated it over the intervention phases of the study. The woman also showed evidence of being aware of response-consequences links. Potential implications and limitations of these findings are discussed.

Influence of musical expertise on segmental and tonal processing in Mandarin Chinese.

A same-different task was used to test the hypothesis that musical expertise improves the discrimination of tonal and segmental (consonant, vowel) variations in a tone language, Mandarin Chinese. Two four-word sequences (prime and target) were presented to French musicians and nonmusicians unfamiliar with Mandarin, and event-related brain potentials were recorded. Musicians detected both tonal and segmental variations more accurately than nonmusicians. Moreover, tonal variations were associated with higher error rate than segmental variations and elicited an increased N2/N3 component that developed 100 msec earlier in musicians than in nonmusicians. Finally, musicians also showed enhanced P3b components to both tonal and segmental variations. These results clearly show that musical expertise influenced the perceptual processing as well as the categorization of linguistic contrasts in a foreign language. They show positive music-to-language transfer effects and open new perspectives for the learning of tone languages.

Sensory-motor brain network connectivity for speech comprehension.

The act of listening to speech activates a large network of brain areas. In the present work, a novel data-driven technique (the combination of independent component analysis and Granger causality) was used to extract brain network dynamics from an fMRI study of passive listening to Words, Pseudo-Words, and Reverse-played words. Using this method we show the functional connectivity modulations among classical language regions (Broca's and Wernicke's areas) and inferior parietal, somatosensory, and motor areas and right cerebellum. Word listening elicited a compact pattern of connectivity within a parieto-somato-motor network and between the superior temporal and inferior frontal gyri. Pseudo-Word stimuli induced activities similar to the Word condition, which were characterized by a highly recurrent connectivity pattern, mostly driven by the temporal lobe activity. Also the Reversed-Word condition revealed an important influence of temporal cortices, but no integrated activity of the parieto-somato-motor network. In parallel, the right cerebellum lost its functional connection with motor areas, present in both Word and Pseudo-Word listening. The inability of the participant to produce the Reversed-Word stimuli also evidenced two separate networks: the first was driven by frontal areas and the right cerebellum toward somatosensory cortices; the second was triggered by temporal and parietal sites towards motor areas. Summing up, our results suggest that semantic content modulates the general compactness of network dynamics as well as the balance between frontal and temporal language areas in driving those dynamics. The degree of reproducibility of auditory speech material modulates the connectivity pattern within and toward somatosensory and motor areas.

How and when auditory action effects impair motor performance.

Music performance is characterized by complex cross-modal interactions, offering a remarkable window into training-induced long-term plasticity and multimodal integration processes. Previous research with pianists has shown that playing a musical score is affected by the concurrent presentation of musical tones. We investigated the nature of this audio-motor coupling by evaluating how congruent and incongruent cross-modal auditory cues affect motor performance at different time intervals. We found facilitation if a congruent sound preceded motor planning with a large Stimulus Onset Asynchrony (SOA -300 and -200 ms), whereas we observed interference when an incongruent sound was presented with shorter SOAs (-200, -100 and 0 ms). Interference and facilitation, instead of developing through time as opposite effects of the same mechanism, showed dissociable time-courses suggesting their derivation from distinct processes. It seems that the motor preparation induced by the auditory cue has different consequences on motor performance according to the congruency with the future motor state the system is planning and the degree of asynchrony between the motor act and the sound presentation. The temporal dissociation we found contributes to the understanding of how perception meets action in the context of audio-motor integration.

Perceptual preferences in depth stratification of transparent layers: Photometric and non-photometric factors.

In three experiments, using a two-alternative forced-choice task, we obtained depth judgments of displays containing transparent regions. The regions varied in lightness, size, and animation. Observers nearly always strongly preferred one certain depth ordering among the regions, even though their lightness conditions were expected to give rise to ambiguity among possible orderings. This expectation was based on the contrast polarity model, which expects ambiguity in the absence of contrast polarity reversal. The expectation was founded also on a stronger condition based on the transmittance anchoring principle, which gives preference to the largest lightness contrast between regions. In the absence of contrast polarity reversal and in conditions of balanced regional contrast, preferences were shown to depend on additional conditions of contrast between two respective regions and their overlap. Depth ordering judgment seems to be based on a critical decision threshold, independently of the coordinate system used to specify lightness. We also investigated the role of non-photometric factors such as motion and relative size, and concluded that these variables can modulate depth ordering judgments in transparency.

Emotion recognition and inhibitory control in manifest and pre-manifest Huntington's disease: evidence from a new Stroop task.

Huntington's disease (HD) is a genetic neurodegenerative disorder that affects not only the motor but also the cognitive domain. In particular, cognitive symptoms such as impaired executive skills and deficits in recognizing other individuals' mental state may emerge many years before the motor symptoms. This study was aimed at testing two cognitive hypotheses suggested by previous research with a new Stroop task created for the purpose: 1) the impairment of emotion recognition in HD is moderated by the emotions' valence, and 2) inhibitory control is impaired in HD. Forty manifest and 20 pre-manifest HD patients and their age- and gender-matched controls completed both the traditional "Stroop Color and Word Test" (SCWT) and the newly created "Stroop Emotion Recognition under Word Interference Task" (SERWIT), which consist in 120 photographs of sad, calm, or happy faces with either congruent or incongruent word interference. On the SERWIT, impaired emotion recognition in manifest HD was moderated by emotion type, with deficits being larger in recognizing sadness and calmness than in recognizing happiness, but it was not moderated by stimulus congruency. On the SCWT, six different interference scores yielded as many different patterns of group effects. Overall our results corroborate the hypothesis that impaired emotion recognition in HD is moderated by the emotions' valence, but do not provide evidence for the hypothesis that inhibitory control is impaired in HD. Further research is needed to learn more about the psychological mechanisms underlying the moderating effect of emotional valence on impaired emotion recognition in HD, and to corroborate the hypothesis that the inhibitory processes involved in Stroop tasks are not impaired in HD. Looking beyond this study, the SERWIT promises to make important contributions to disentangling the cognitive and the psychomotor aspects of neurological disorders. The research was approved by the Ethics Committee of the "Istituto Leonarda Vaccari", Rome on January 24, 2018.

Semantic encoding in working memory: is there a (multi)modality effect?

In spite of a large body of empirical research demonstrating the importance of multisensory integration in cognition, there is still little research about multimodal encoding and maintenance effects in working memory. In this study we investigated multimodal encoding in working memory by means of an immediate serial recall task with different modality and format conditions. In a first non-verbal condition participants were presented with sequences of non-verbal inputs representing familiar (concrete) objects, either in visual, auditory or audio-visual formats. In a second verbal condition participants were presented with written, spoken, or bimodally presented words denoting the same objects represented by pictures or sounds in the non-verbal condition. The effects of articulatory suppression were assessed in both conditions. We found a bimodal superiority effect on memory span with non-verbal material, and a larger span with auditory (or bimodal) versus visual presentation with verbal material, with a significant effect of articulatory suppression in the two conditions.

Learning as a possible sign of non-reflective consciousness in persons with a diagnosis of vegetative state and pervasive motor impairment.

A diagnosis of vegetative state represents a serious predicament, which basically precludes/minimizes rehabilitation perspectives. Reliability of the assessment approach in these situations is of paramount importance, but not easy to achieve. In recent studies, a learning assessment procedure has been suggested as a supplement in the diagnostic process and assessed with eight patients. The procedure involves an ABABCB sequence in which A represents baseline phases with no stimulation available, B intervention phases with stimuli delivered contingently on target responses, and C a control condition. This condition involves stimulation presented non-contingently. The patients' ability to associate responding with environmental stimuli and thus increase such responding during the B phases, and reduce it during the A and C phases, may be considered a sign of learning. Learning might be viewed as representative of forms of concrete knowledge and presumably basic levels of consciousness. Preliminary results indicate that (a) signs of learning may appear in patients with a previous diagnosis of vegetative state and (b) the presence of those signs may require a revision of their diagnostic label and a reappraisal of their rehabilitation perspectives.

Perceptual load affects exogenous spatial orienting while working memory load does not.

We examined whether or not increasing visual perceptual load or visual working memory (WM) load would affect the exogenous orienting of visuo-spatial attention, in order to assess whether or not exogenous orienting is genuinely automatic. In Experiment 1, we manipulated visual perceptual load by means of a central morphing shape that in some trials morphed into a particular target shape (a rectangle) that participants had to detect. In Experiment 2, the possibility that the presentation of any changing stimulus at fixation would eliminate exogenous orienting was ruled out, by presenting two alternating letters at fixation. In Experiment 3, we manipulated visual WM load by means of arrays consisting of three (low-load) or five (high-load) randomly located coloured squares. The participants had to remember these items in order to judge whether a cued square had been presented in the same or different colour at the end of each trial. In all the experiments, exogenous visuo-spatial attentional orienting was measured by means of an orthogonal spatial cuing task, in which the participants had to discriminate the elevation (up vs. down) of a visual target previously cued by a spatially nonpredictive visual cue. The results showed that increasing the perceptual load of the task eliminated the exogenous orienting of visuo-spatial attention. By contrast, increasing the WM load had no effect on spatial orienting. These results are discussed in terms of the light that they shed on claims regarding the automaticity of visuo-spatial exogenous orienting.

Are vertical meridian effects due to audio-visual interference? A new confirmation with deaf subjects.

PURPOSE: Specific increases of reaction times (RTs) were found in normal subjects, when endogenous spatial cues and targets were separated by the vertical visual meridian (VM) or by the vertical auditory (AM) meridian, when targets were either visual or auditory. The aim of this study was to assess if this effect could be attributed to longer RTs needed to shift activation between the hemispheres, or rather to different spatial maps underlying visual and auditory attention. METHOD: We tested the VM effect in deaf subjects. If the shifting of activation from one hemisphere to the other causes the increase in RTs, then no differences between normal and sensory disabled people should take place, as the incoming perceptual information in the residual modality uses the same neural pathways while crossing the vertical meridian. Conversely, if the vertical meridian effects are related to the spatial representation systems underlying endogenous orienting mechanisms, then the lack of the auditory perceptual system in deaf people may have determined different organization processes in the brain circuits, strongly affecting the orienting mechanisms of spatial attention. RESULTS: Compared with a control group of hearing subjects, we found no evidence of the VM effect in deaf subjects. CONCLUSIONS: This finding, jointly with those of a previous experiment which showed no AM effect on blind subjects (Olivetti Belardinelli & Santangelo 2005) supports the idea of different spatial maps underlying visual and auditory attention, and suggests that their co-existence may induce interference effects in space processing, giving rise to the anisotropic representation of visual and auditory spaces, observed in normal subjects.

Patients with moderate Alzheimer's disease engage in verbal reminiscence with the support of a computer-aided program: a pilot study.

This study focused on the assessment of a program recently developed for helping patients with moderate Alzheimer's disease engage in computer-mediated verbal reminiscence (Lancioni et al., 2014a). Sixteen participants were involved in the study. Six of them used the original program version with the computer showing a virtual partner posing questions and providing attention and guidance. The other 10 used a slightly modified program version with the computer presenting photos and videos and providing encouragements to talk as well as attention and guidance. Participants were exposed to brief program sessions individually. The results showed that 15 participants (five of those using the first version and all of those using the second version) had a clear and lasting increase in verbal engagement/reminiscence during the intervention sessions with the program. Those 15 participants had mean percentages of intervals with verbal engagement/reminiscence below 10 during baseline and between about 45 and 75 during the intervention. The results' implications and the need for new research were discussed.

Supporting self-managed leisure engagement and communication in post-coma persons with multiple disabilities.

Post-coma persons affected by extensive motor impairment and lack of speech, with or without disorders of consciousness, need special support to manage leisure engagement and communication. These two studies extended research efforts aimed at assessing basic technology-aided programs to provide such support. Specifically, Study I assessed a program for promoting independent stimulation choice in four post-coma persons who combined motor and speech disabilities with disorders of consciousness (i.e., were rated between the minimally conscious state and the emergence from such state). Study II assessed a program for promoting independent television operation and basic communication in three post-coma participants who, contrary to those involved in Study I, did not have disorders of consciousness (i.e., had emerged from a minimally conscious state). The results of the studies were largely positive with substantial levels of independent stimulation choice and access for the participants of Study I and independent television operation and communication for the participants of Study II. The results were analyzed in relation to previous data in the area and in terms of their implications for daily contexts dealing with these persons.