The "neglected" Personal Neglect

REVIEW The ‘Neglected’Personal Neglect Pietro Caggiano 1 &Mervi Jehkonen 2,3 Received: 17 June 2018 /Accepted: 14 November 2018 /Published online: 13 December 2018 Abstract A review of patients with brain injury showing personal neglect is presented. The aim is to shed light on this aspect of neglect often unresearched or only indirectly investigated, and to discuss recent findings concerning the methods used to assess personal neglect, its neural correlates and its association with the more often explored aspect of extrapersonal neglect. The review was performed using PubMed and PsychInfo databases to search for papers published in the last 123 years (until January 2018). We reviewed 81 papers describing either single or group studies for a total of 2247 patients. The results of this review showed that various aspects of personal neglect are still controversial and outcomes potentially contradictory. Despite the data reported in the present review suggest that personal neglect is more frequently associated with lesions of the right hemisphere, the left hemisphere may also play an important role. Not surprisingly, personal neglect and extrapersonal neglect seem to co-occur. However double dissociations of these two forms of neglect have been reported, and they seem to dissociate both from a functional and an anatomical perspective. More recent interpretations of personal neglect suggest that it may result from a disrupted body representation. The development of reliable psychometric tools with shared diagnostic criteria is essential to identify different degrees of personal neglect for different body parts and to better refine personal neglect in comparison to extrapersonal neglect and disorders related to distortions of personal domain. Keywords Anosognosia .Assessment .Braindamage .Hemispatialneglect .Neuropsychology .Personalneglect .Extrapersonal neglect .Stroke Introduction Hemispatial neglect is a well-known and relatively common deficit following unilateral brain lesions and it refers to a variety of acquired neuropsychological disorders that affect spatial cognition (see Halligan, Fink, Marshall, & Vallar, 2003; Vallar, 1998 for reviews). The main feature of hemispatial neglect is a general lack of awareness and attention to stimuli located in the contralesional side of space and not due to elementary sensory or motor disorders. Hemispatial neglect can be fractionated into different patterns of impairment according to the specific frame of reference (personal, reaching space and far extrapersonal) that can be selectively affected according to distinct coordinates (Vallar, 1998). Personal neglect refers to a form of hemi-inattention where brain-injured patients show a Bdeficit relative to the side of the body contralateral to the lesion^(Guariglia & Antonucci, 1992;p.1001).Thisdefinitionof‘personal neglect’seems to imply a general inattention for the contralesional side of the body. However, different attentional deficits can be related to the contralesional limb. In 1893, Gabriel Anton described the case of a patient who exhibited a deficit of tactile and pain sensation on the left side, as well as proprioceptive impairment of position sense. The loss of both the perception and the Bknowledge^of the left side fits with the current definition of personal neglect. However, it is widely accepted in the neuropsychological literature that the first clear observation of personal neglect was made in 1913, by Hermann Zingerle, who referred to Anton’s case. Zingerle described two patients with right brain-injury (cases 2 and 3) both of whom failed to spontaneously attend to the left side of their own body. Referring to case 2, Zingerle noted that the patient Bnever drew his attention to it [ …] apparently never missed it, and seemed to have completely forgotten about it^(translation as in Benke, *Pietro Caggiano [email protected] 1 Psychology Department, Goldsmiths University of London, New Cross, London SE14 6NW, UK 2 Faculty of Social Sciences, University of Tampere, Tampere, Finland 3 Department of Neurology and Rehabilitation, Tampere University Hospital, Tampere, Finland Neuropsychology Review (2018) 28:417–435 https://doi.org/10.1007/s11065-018-9394-4 #The Author(s) 2018 Luzzatti, & Vallar, 2004; p. 268). With case 3, Zingerle stated that Bthe patient did not use his left arm at all for spontaneous movements [ …] it was impossible to obtain comments about his left side or a description of the sensations on that side.^ (translation as in Benke et al., 2004;p.270).Zingerle’searly descriptions seem to reflect different possible deficits associated with neglect in the personal domain: motor and premotor neglect. The term motor neglect (Laplane & Degos, 1983) refers to patients that show a considerable reduction in spontaneous use of their contralesional limbs (as in Zingerle’scase 3), which is not explained by their associated motor impairments (e.g., Punt & Riddoch, 2006; Sampanis & Riddoch, 2013). On the other hand, premotor neglect (Heilman, Bowers, Coslett, Whelan, & Watson, 1985; Bisiach, Vallar, Perani, Papagno, & Berti, 1986b) refers to patients, like Zingerle’s cases 2 and 3, who show a reduced tendency to perform movements with the ipsilesional (unimpaired) limbs toward the contralesional side of their body (Bisiach, Perani, Vallar, & Berti, 1986a)aswellas within peripersonal space (Saevarsson, Eger, & Gutierrez-Herrera, 2014). The relationship between motor and premotor neglect is still unclear and investigation of these two forms of neglect is rarely carried out in the same sample (e.g., Garbarini et al., 2012; Buxbaum et al., 2004). Despite the fact that both motor and premotor neglect within personal space should intuitively fall under the umbrella of ‘personal neglect’, the term personal neglect has often been used to identify the premotor form. As such, we re-direct the reader interested in motor neglect to a review by Punt and Riddoch (2006; see also Sampanis & Riddoch, 2013), as this review will mainly focus on personal neglect defined as a set of spatially asymmetrical symptoms occurring in personal space including: defective awareness of the contralesional side of the body, a lack of awareness of contralesional tactile or proprioceptive stimuli and defective motor programming towards targets in the neglected sector of space (Vallar, 1998). Patients tend to neglect the contralesional side of their body, for example, they may forget to shave the left side of their face or fail to properly dress the left side of their body (e.g. not put the left arm in the left sleeve of a shirt). The aim of this review is to elucidate different aspects and findings of this specific type of neglect, which is often overlooked or investigated indirectly, by appraising research undertaken since Anton’s first description. Studies on Personal Neglect: A Systematic Literature Review The literature on personal neglect is quite fragmented, with inconsistent definitions and assessment methods. This lack of clarity causes difficulties in understanding and defining such an impairment and has implications for both theoretical and clinical or diagnostic purposes. A recent review from Committeri, Piervincenzi and Pizzamiglio (2018) provides a useful re-evaluation of the theoretical accounts and neuroanatomical correlates of personal neglect, highlighting the association of personal neglect with a variety of body representation disorders. The present review offers a systematic update on relevant research and frames personal neglect in terms of its assessment methods, neural substrates and its relationship with inattention for extrapersonal space. Method The review was performed using PubMed and PsychInfo databases to search for papers published before January 2018. Following an initial search with the keywords: personal neglect and stroke;personal neglect and brain damage;personal neglect and lesion; body representation neglect, we identified 62 papers that mentioned personal neglect as part of an empirical study or review paper. We initially considered English language papers only, though crucial, historical papers in different languages (e.g. Anton, 1893;Zingerle,1913) were also considered. As part of a second additional search, we scrutinized various papers and reviews on neglect (i.e., Azouvi et al., 2006; List, Brooks, Esterman, & Flevaris, 2008; Rode, Pagliari, Huchon, Rossetti, & Pisella, 2016; Vallar & Ronchi, 2009;Jehkonen, Laihosalo, & Kettunen, 2006) and on associated disorders, such as anosognosia (e.g., Appelros, Karlsson, Seiger, & Nydevik, 2002; Cocchini, Beschin, & Sala, 2002;Buxbaum et al., 2004; Berti, Làdavas, & Della Corte, 1996)toidentify further studies about personal neglect, some of which were not published in English. Additionally, for the purpose of the present review, we did not consider forms of neglect which explicitly referred to the clinical description of motor neglect provided by Laplane and Degos (1983) and schematized in the work of Punt and Riddoch (2006). Results and Discussion We finally considered a sample of 81 papers (51 reporting single cases and 30 reporting group studies) published in the last 123 years (between 1893 and 2018). The number of patients in the 81 studies ranged from 1 (single case studies) to 282 (group studies). Table 1reports demographic and clinical information of 51 papers describing 83 single or multiple cases showing personal neglect. Table 2includes 30 group studies in which personal neglect was assessed as the primary purpose of the studies or as a control variable. The sample size of group studies ranges from eight (Reinhart et al., 2012)to 282 (Guariglia et al., 2014) patients for a total sample size of 2247 patients, of which 755 were reported to have personal 418 Neuropsychol Rev (2018) 28:417–435 Table 1 Demographic, clinical and neuropsychological data of 83 brain-injured patients showing evidence of personal neglect described in 51 single-case studies Author/s Assessment method Case N Gender Age/ mean age Aetiology Onset (days) Lesion side Lesion site (main structures) EN Anton, 1893 Clinical observation #1 M 65 Vascular na R O, thalamus + Zingerle, 1913 Clinical observation #2 M 45 Vascular ‘acute’Rna na Kramer, 1915 Clinical observation #1 M na Vascular na R na + Barré, Morin, & Kaiser, 1923 Clinical observation #1 M 60 Vascular na R na + Barkman, 1925 Clinical observation #9 F 53 Vascular na R na + Ehrenwald, 1930 Clinical observation #1 M 59 Vascular na R na na Ehrenwald, 1931 Clinical observation #5 M 64 Vascular na R na + Potzl quoted by Schilder (1935) Clinical observation #1 M na Vascular na R P, internal capsule + #2 M na Vascular na R P, O, thalamus na Lhermitte & Tchehrazi, 1937 Clinical observation #1 M 70 Vascular na R F, T, P na Von Hagen & Ives, 1937 Clinical observation #1 F 48 Vascular na R na + Garcin,Varay,& Hadji-Dimo, 1938 Clinical observation #1 M 64 Tumor na R T, P – Rubinstein, 1941 Clinical observation #4 F 63 Vascular na R na + Wortis & Dattner, 1942 Clinical observation #1 F 78 Vascular na R F,T,P (MCI territory) + Gerstmann, 1942 Clinical observation #2 F 38 Vascular na R na + Sandifer, 1946 Clinical observation #1 F 66 Vascular na R P, T, thalamus + Roth, 1949 Clinical observation #1 F 61 Tumor na L/R P, F, T, white matter + #2 M 51 Vascular na R ICA territory na Weinstein & Kahan, 1950 Clinical observation #7 F 38 Tumor na R T na Weinstein, Kahn, Malitz, &Rozanski,1954 Clinical observation #1 F 57 Vascular & Tumor na R cingulate gyrus + Frederiks, 1963 Clinical observation #1 M 36 Vascular na R T na Verret & Lapresle, 1978 Clinical observation #1 F 64 Vascular na R T na Healton, Navarro, Bressman, & Brust, 1982 Clinical observation #1 F 75 Vascular na R basal ganglia, lenticular nucleus, external capsule + Nightingale, 1982 Clinical observation #1 M 46 Tumor na R P na Assal, 1983 Clinical observation #1 F 86 Vascular na R T + Berthier & Starkstein, 1987 Clinical observation #1 M 63 Vascular na R F T P + Starkstein, Berthier, Fedoro, Price, & Robinson, 1990 One Item test #1 M 71 Vascular na R F, cingulate gyrus, corpus callosum + #2 F 48 Vascular na R Territory of MCA + Bisiach, Meregalli, & Berti, 1990 One Item test #1 M 74 Vascular na R T, P, O + Neuropsychol Rev (2018) 28:417–435 419 Table 1 (continued) Author/s Assessment method Case N Gender Age/ mean age Aetiology Onset (days) Lesion side Lesion site (main structures) EN Rode et al., 1992 One Item Test #1 F 69 Vascular na R P, T, O, subcortical structures + Zoccolotti & Judica, 1991 SFES-P #1 M 43 Vascular na L/R right F, T, P; left cerebellum – Guariglia & Antonucci, 1992 SFES-P, BRT #1 M 42 Vascular na R F, P, subcortial structures – Halligan, 1995 Clinical observation #1 M 41 Vascular na R T, P + Aglioti, Smania, Manfredi, & Berlucchi, 1996 na #1 F 73 Vascular 4 R F,T,P,O, subcortical structures + Beschin, Cocchini, Della Sala, & Logie, 1997 One item test, Fluff test, Comb and Razor/ Compact #1 M 67 Vascular 16 R P – Peru & Pinna, 1997 One item test #1 F 56 Vascular 35 L T – Coslett, 1998 Clinical observation #1 na 72 na 730 R F, T, P + #2 na 52 na 21 R F, P + #3 M 67 Vascular 365 R P + Schiff & Pulver, 1999 Clinical observation #1 F 81 Vascular na L F, T, P, O + Paulig, Weber, & Garbelotto, 2000 Clinical observation #1 F 85 Vascular na R PCA territory, including deep branches (thalamus) + Beschin, Basso, & Della Sala, 2000 One item test, Fluff test, Comb and Razor/ Compact #1 M 67 Vascular 1460 L/R left P, O, right thalamus + Tei, 2000 Clinical observation #1 F 76 Vascular 2 R F, P + Bottini, Bisiach, Sterzi, & Vallar, 2002 One item test #1 F 77 Vascular ‘acute’R insula, internal capsule, others white matter tracts + Cocchini et al., 2002 Comb and Razor/ Compact, Fluff test, One item test #1 M 27 TBI 182 R/L left & right F; right F, P, internal capsule; left T + Maguire & Ogden, 2002 One item test #1 F 54.8 Vascular 28–42 L F, T, thalamus, basal ganglia + #2 F Vascular R F, T, basal ganglia + #3 F Vascular R F, T, P, basal ganglia + #4 M Vascular R F, T, P, basal ganglia + #5 M Vascular R F, T, P, basal ganglia + #6 M Vascular R F, T, basal ganglia + #7 M Vascular R F, T, P, basal ganglia + #8 M Vascular R F, P basal ganglia + #9 M Vascular R F, P basal ganglia + Marangolo, Piccardi, & Rinaldi, 2003 SFES-P, BRT #1 M 78 Vascular 122 R F-P, T, subcortical structures – Moro, Zampini, & Aglioti, 2004 Comb and Razor/ Compact #1 F 62 Vascular 213 R F, T, P + #2 M 66 Vascular 33 R F,T,P, subcortical structures + 420 Neuropsychol Rev (2018) 28:417–435 Table 1 (continued) Author/s Assessment method Case N Gender Age/ mean age Aetiology Onset (days) Lesion side Lesion site (main structures) EN Ortigue, Mégevand, Perren, Landis, & Blanke, 2006 One item test, Fluff test, Comb and Razor/ Compact #1 M 67 Vascular ‘acute’R internal capsule – Garbarinietal.,2012 Fluff test #1 na 66 Vascular 62 R F, P, thalamus, external capsule, caudate + #2 na 84 Vascular 32 R P, putamen, internal and external capsule, insula, others + #4 na 76 Vascular 27 R F, T, P, internal and external capsule, others + #6 na 62 Vascular 36 R T, P, thalamus, posterior insula, others + #8 na 79 Vascular 31 R O, T, P, posterior insula and internal capsule + #10 na 71 Vascular 30 R F, T, others + Sambo et al., 2012 One Item Test, Fluff test #1 M 77 Vascular 425 R basal ganglia + One Item Test, Fluff test #2 M 36 Vascular 365 R F,T basal ganglia + One Item Test, One Item (extended) #3 M 76 Vascular 335 R F,T,P + One Item Test, One Item (extended) #4 M 69 Vascular 30 R F,T,P + Invernizzi et al., 2013 One item test #1 F 60 Vascular 5 R thalamus, basal ganglia + #2 F 69 Vascular 3 R F, T,P, basal ganglia, thalamus + #3 M 71 Vascular 5 R thalamus, basal ganglia + #4 F 84 Vascular 21 R T, O, thalamus, basal ganglia, internal capsule + #5 M 70 Vascular 1 R thalamus, basal ganglia, internal capsule + Di Vita, Palermo, Piccardi, & Guariglia, 2015 SFES-P, BRT #1 M 63 Vascular 10 R F, T, P, insula + Di Vita et al., 2016 SFES-P, BRT #2 F 75 Vascular 10–90 L insula, external capsule, putamen + #8 M 47 Vascular R internal capsule, corona radiata + #11 M 74 Vascular R F, T – #12 F 65 Vascular R na + #14 M 64 Vascular R temporal-parietal junction – #15 M 58 Vascular R P – #18 M 74 Vascular R striatum, capsule – Facchin, Beschin, & Daini, 2016 Comb and Razor/ Compact, Fluff test #1 M 49 Vascular 180 L T,P, insula, putamen, internal capsule, superior lateral fasciculus + One Item test, Fluff test #1 M 58 Vascular 14 R subcortical + Neuropsychol Rev (2018) 28:417–435 421 neglect (33.6%). Details of these studies are discussed in the sections below considering three aspects that we consider crucial in order to better understand the implications of personal neglect for future research and clinical purposes i) assessment methods, ii) neural correlates of personal neglect and iii) the relationship of personal neglect with extrapersonal neglect. i) Assessment methods Tables 1and 2report the assessment methods used in each study included in this review, and Table 3provides a brief description of the most common tests used to assess personal neglect and how extensively they have been used. Despite a range of diagnostic methods having been developed to assess personal neglect and distortion of personal domain (see Table 3), in the majority (57%; 29/51) of the single case studies reported in Table 1, personal neglect was diagnosed by means of clinical observation. Only 20% (10/ 51) of the studies used one psychometric test, and as few as 22% (11/51) of the studies used two or three tests to assess personal neglect (seven and four studies respectively). In the group studies (Table 2) personal neglect was assessed more systematically with nearly all studies adopting at least one psychometric test (97%; 29/30). In about a third (30%; 9/30) of the studies personal neglect was investigated by means of two different tests, and only 7% (2/30) of the studies used three different measures to assess personal neglect. This is rather surprising if we consider that other forms of neglect, such as extrapersonal neglect, are usually examined through the use of a wider battery of tests to reflect the complexity of extrapersonal neglect (e.g., Behavioural Inattention Test; Wilson, Cockburn, & Halligan, 1987). Interestingly, when more than one personal neglect assessment method was used, the researchers observed a heterogeneous picture (e.g. Bowen et al., 2005; Azouvi et al., 2006; Glocker et al., 2006; Rousseaux et al., 2013;Caggianoetal.,2014), suggesting that personal neglect may be a term that encompasses disruption of different underlying mechanisms. A possible reason for the lack of systematic investigations into the literature concerning personal neglect may be due to the fact that personal neglect was not investigated in group studies until 1978 (Cutting, 1978), more than 60 years after its first description. During this period, personal neglect was mainly described in single case studies where the research focused on the clinical evidence for this syndrome (Table 1). One of the first attempts to systematically investigate personal neglect was not until 1986 when Bisiach and colleagues (Bisiach et al., 1986a) devised the One Item Test (Table 3) and reported that 39% of 97 patients showed personal neglect. The One Item test represents a very easy and quick way to assess evidence of personal neglect and has been extensively used for clinical and research purposes in at least 23 studies. This scale has been recently modified to allow evaluation of other body parts such as ear, shoulder, Table 1 (continued) Author/s Assessment method Case N Gender Age/ mean age Aetiology Onset (days) Lesion side Lesion site (main structures) EN Ronchi, Heydrich, Serino, & Blanke, 2017 Total number of patients 83 M = 46; F = 29; na = 8 Mean = 63.2 SD = 13.4 Vascular = 75; Tumor = 4; Vascular&Tumor = 1; TBI = 1; na = 2 Mean = 152.5 SD = 290.9# 76 RBD; 5 LBD; 2 Bilateral Total number of patients showing associated disorders 63/74 (85.- 1%) SFES-P, Semistructured Functional Evaluation Scale - Personal sub-scale; BRT, Body Representation Test; TBI, Traumatic Brain Injury; LBD,LeftBrainDamage;RBD, Right Brain Damage; F, Female; M, Male; na, not available; F, Frontal, T,Temporal;P, Parietal; O, Occipital lobes; R, Right; L,Left;MCA, Middle Cerebral Artery; ICA Inferior Cerebral Artery; PCA, Posterior Cerebral Artery; PN, Personal Neglect; EN, Extrapersonal Neglect; ‘acute’, as reported by authors; less than 7 days; na, information not available + deficit present −deficit absent #where range was available, the average of the group onset was considered 422 Neuropsychol Rev (2018) 28:417–435 Table 2 Assessment method, clinical and neuropsychological details of the 30 group studies reporting evidence of personal neglect Author/s Assessment method Aetiology Lesion side Lesion site (main structures) PN (sample) PN % EN (PN) Cutting, 1978 Clinical observation Vascular R na 10 (48) 21 10 (10) Bisiach et al., 1986a,bOne item test Vascular & tumor R P, thalamus, internal capsule, lenticular nucleus 38 (97) 40.2 37 (38) Zoccolotti & Judica, 1991 SFES-P Vascular R na 22 (26) 84.6 22 (22) Beschin & Robertson, 1997 Comb and Razor/Compact Vascular R na 15 (31) 48.4 10 (15) McIntosh, Brodie, Beschin, & Robertson, 2000 Comb and Razor/Compact Vascular R na 20 (31) 64.5 14 (20) Cocchini, Beschin, & Jehkonen, 2001 Fluff test; Comb and Razor/Compact Vascular R na 12 (27) 44.4 10 (27) Vascular L na 2 (11) 18.2 0 (2) Appelros et al., 2002 SFES-P, One item test Vascular R na 18 (126) 14.3 18 (18) L na 4(146) 2.7 4 (4) Azouvi et al., 2002 One item test (eyes open) na R na na 16.0 na One item test (eyes closed) 13.0 Azouvi et al., 2003 CBS Vascular R na 82 (83) 99.0 82 (82) Appelros et al., 2004 SFES-P Vascular R na 23 (37) 62.5 23 (23) Beis et al., 2004 One item test (eyes open) Vascular L F, P, T, O, internal capsule, thalamus 7 (78) 8.9 na One item test (eyes closed) 10 (78) 12.8 Buxbaum et al., 2004 Fluff test (modified) Vascular R F, T, O, P, cingulate gyrus, periventricular white matter, basal ganglia, internal capsule, thalamus# 28 (166) 16.9 26 (28) Bowen, Gardener, Cross, Tyrrell, & Graham, 2005 One item test, Fluff test (modified), Face Washing Vascular R na 20 (42) 47.6 12 (20) Azouvi et al., 2006 One item test (eyes open) Vascular R F,T, subcortical 33 (206) 16.0 33 (33) L 7 (78) 9.0 7 (7) One item test (eyes closed) R 27 (206) 13.0 27 (27) L 10 (78) 12.8 10 (10) Glocker, Bittl, & Kerkhoff, 2006 CBS, Vest Test Vascular R na 20 (25) 80 na L 12 (25) 48 Fluff test (modified) R 17 (25) 68 L 12 (25) 48 Committeri et al., 2007 SFES-P Vascular R P (postcentral and supramarginal gyrus), white matter supralenticular corona radiata, centrum semiovale## 30 (52) 57.7 22 (30) Lindell et al., 2007 SFES-P, One item test Vascular R F, T, P, white matter 10 (34) 29.4 10 (10) Groh-Bordin et al., 2009 Vest Test Vascular L F, white matter 7 (23) 30.4 na Baas et al., 2011 Fluff test Vascular R T, P 7 (22) 31.8 7 (7) Fortis et al., 2010 CBS, One Item test (extended) Vascular R F, P, T; white matter; basal ganglia 4 (10) 40 4 (4) Reinhart et al., 2012 Vest Test Vascular R F, T, P, thalamus, basal ganglia 8 (8) 100 8 (8) Neuropsychol Rev (2018) 28:417–435 423 Table 2 (continued) Author/s Assessment method Aetiology Lesion side Lesion site (main structures) PN (sample) PN % EN (PN) Rousseaux, Sauer, Saj, Bernati, & Honoré, 2013 CBS Vascular R F, T, P, rolandic cortex, centrum ovale, insula,internal capsule, striatum, thalamus 9 (15) 60.0 9 (9) One Item test R 1 (15) 7.0 1 (1) Caggiano, Beschin, & Cocchini, 2014 Comb and Razor/Compact Vascular R F,T,P 27 (101) 26.7 na L 21 (96) 21.9 Fluff test (eyes open) R 23 (101) 22.8 L 21 (96) 21.9 Fluff test (eyes closed) R 36 (101) 35.6 L 20 (96) 20.8 Guariglia, Matano, & Piccardi, 2014 SFES-P Vascular R F,T,P,O,insula,basal ganglia, internal capsula, lenticualr nucleus,coronaradiata 122 (282) 43.3 95 (122) Palermo, Di Vita, Piccardi, Traballesi, & Guariglia, 2014 SFES-P, BRT Vascular R F, T, P, O, internal and external capsula, corona radiata, basal ganglia, thalamus, insula 13 (32) 49.6 13 (13) Iosa, Guariglia, Matano, Paolucci, &Pizzamiglio,2016 SFES-P Vascular R na 35 (49) 71.4 35 (35) Rousseaux, Allart, Bernati, & Saj, 2015 One Item test, SSA, CBS Vascular R F, P, T, temporo-occipital junction, white matter 29 (45) 64.4 21 (29) Besharati et al., 2016 One Item Test, Comb and Razor/Compact Vascular R F (inferior / middle gyri), P (inferior), T (superior gyri), insula, dorsal-frontal white matter # na (30) na na Moro et al., 2016 Comb and Razor/Compact Vascular R F, P, T, superior temporal gyrus, insula, basal ganglia, corona radiata, external capsule na (66) na na Spaccavento, Cellamare, Falcone, Loverre, & Nardulli, 2017 SFES-P Vascular R na 60 (130) 46 45 (60) Total number of patients 755 (2247) SFES-P, Semistructured Functional Evaluation Scale - Personal sub-scale; BRT, Body Representation Test; SSA, Subjective Straight Ahead; CBS, Catherine Bergego Scale; F, Frontal, T, temporal; P, Parietal; O, Occipital lobes; R, Right; L,Left;PN, Personal Neglect; EN, Extrapersonal Neglect; na, information not available # sites of lesions of entire sample (i.e. not limited to patients showing PN) ## lesion sites for patients showing PN 424 Neuropsychol Rev (2018) 28:417–435 elbow, wrist, waist and knee (Fortis et al., 2010). However, the test also presents some limitations. It usually consists of a single trial assessing a limited area, such as the contralateral arm. More importantly, the command per se (i.e. BWith this hand, touch your other hand^) implies the existence of the contralesional limb. This may result in the patient attempting to reach for a limb, otherwise neglected, thus potentially leading to a false negative result. Finally, the search for the contralesional limb is guided by proprioceptive information providing little insight into the patient’smental representation of their own body (Cocchini et al., 2001). To respond to some of these limitations, Zoccolotti and Judica (1991) devised the Semistructured Functional Evaluation Scale (SFES), which includes a semi-structured scale assessing difficulties relating to personal space.The ‘Personal sub-scale’(SFES-P) requires the use of everyday objects, such as a comb, a razor (for males), powder (for women) and glasses, with the examiner assigning a score from 0 (normal performance) to 3 (severe personal neglect). The rating, depending on the examiner’s expertise, provides a general indication of the presence or absence of personal neglect but this rating seems less able to establish different degrees of personal neglect severity, resulting in an underestimation of less severe forms (Beschin & Robertson, 1997). To improve the objectivity of the assessment of personal neglect, Beschin and Robertson (1997) developed the Comb and Razor/Compact Test where the examiner considers the number of strokes applied by the patient on each side of their own face (when asked to pretend to shave or apply make-up) or on each side of their head (when asked to pretend to comb their hair). Patient’s performance was then compared with normative data and 48% of patients with right-sided brain damage had a pathological performance in the Comb and Razor/Compact Test. Interestingly, in the same study 12 patients showed a double dissociation between extrapersonal neglect and personal neglect. The scoring was later revised by McIntosh and colleagues (McIntosh et al., 2000), who proposed a new formula and cut-off criterion to account for possible biases due to ambiguous response strokes (i.e. responses not clearly assigned on either side). It must be considered though, that both the Comb and Razor/Compact test and the SFES-P did not extend the investigation to other parts of the body. Such investigation may be crucial as it is widely accepted that personal neglect also refers to lack of exploration of part of the body. To this aim, Cocchini and colleagues (Cocchini et al., 2001) developed the Fluff Test, where blindfolded patients were required to remove 24 circles previously attached on the patient’sclothes in order to cover the contralesional arm, the torso and both legs. Scoring was based on the number of targets removed on each side and the diagnostic cut-off was based on normative group performance. Clinical findings on 38 brain-damaged patients (27 with right and 11 with left unilateral lesions) confirmed a relatively high percentage of personal neglect (44%) following right brain lesion and a lower, though not negligible, percentage (20%) following left-sided brain damage. In Cocchini and colleagues (Cocchini et al., 2001)study the authors also reported six cases of double dissociation between extrapersonal neglect and personal neglect, and a low correlation between these two forms of neglect. These findings seem consistent with previous studies also showing dissociations between the personal and extrapersonal spaces (Guariglia & Antonucci, 1992; Peru & Pinna, 1997; Bisiach et al., 1986a;Beschin&Robertson,1997; Bailey, Riddoch, & Crome, 2000). However, Glocker and collaborators (Glocker et al., 2006) reported a considerably higher frequency of personal neglect assessed by means of the Vest Test, where patients are asked to search for 24 everyday objects hidden in 24 pockets on a vest, and a modified version of the Fluff test, where targets were attached on a long jacket worn by the patients. In a sample of 25 patients with right-sided brain damage and 25 with left-sided brain damage, up to 80% of the patients with right-sided damage and 48% of those with left-sided damage showed personal neglect on the Vest test, whereas up to 68% of the patients with right-sided damage and 48% of those with left damage showed personal neglect when the modified Fluff test was used. The different findings on frequency may be due to different inclusion criteria used in the studies. However, it should be a matter of careful consideration if relatively small methodological changes, as those between the Vest test and the modified Fluff test, have led to such different diagnostic outcomes in the same sample (e.g. 80% versus 68% of those with right damage). Contradictory results have been observed also in a study by Bowen and collaborators (Bowen et al., 2005) when personal neglect was assessed by means of the Face Washing test, where patients are asked to wipe their face for 20 s with the right hand. In this test, the time spent on the left side of the face is compared with the time spent on the right side. Results of the pilot study did not seem to be in line with other personal neglect tests adopted for the preliminary assessment, such as the One Item Test and the Fluff test. The authors considered the duration of the test as a possible methodological bias. Indeed, 20 s may be an unusually long time to wipe one’s own face and this may have led the patients to clean their face more carefully than they would normally do, spending more time and eventually moving on to the left areas. Unfortunately, the authors only reported data on the total time spent on either the left or right side of the face, not providing information on potential differences between each side of the face during the first few seconds of the task. Focusing on a shorter window of time could have provided valid data about latent personal neglect and a modified version of ths task may represent a further valuable measure to assess personal neglect. In line with the attempt to maintain some type of ecological validity in assessing personal neglect, methods requiring Neuropsychol Rev (2018) 28:417–435 425 Publisher’sNoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References Aglioti, S. M., Smania, N., Manfredi, M., & Berlucchi, G. (1996). Disownership of left hand and objects related to it in a patient with right brain damage. Neuroreport, 8(1), 293–296. Andrews, K., Brocklehurst, J. C., Richards, B., & Laycock, P. J. 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