Higher Cognition James H. Baños, Ph.D. Department of Physical Medicine and Rehabilitation

Higher Cognition

James H. Baños, Ph.D.James H. Baños, Ph.D.

Department of Physical Medicine and RehabilitationDepartment of Physical Medicine and Rehabilitation

Overview

• The Damaged and Undamaged BrainThe Damaged and Undamaged Brain

• Principles of OrganizationPrinciples of Organization

• Principles in Action: Domains of CognitionPrinciples in Action: Domains of Cognition

The Damaged and Undamaged Brain


““The deficits observed after a brain lesion don’tThe deficits observed after a brain lesion don’t

tell you what the lesioned portion of the brain did. tell you what the lesioned portion of the brain did.

They tell you what the rest of the brain is still They tell you what the rest of the brain is still

capable of doing.”capable of doing.”

- John Gabrieli- John Gabrieli


• Neural processing rarely occurs in a simple Neural processing rarely occurs in a simple linear or sequential fashionlinear or sequential fashion

• Instead, it often occurs in continuous “loops” Instead, it often occurs in continuous “loops”

• Like a water faucet that is always running. Like a water faucet that is always running.


• The nervous system thrives on balance and homeostasis of The nervous system thrives on balance and homeostasis of neural processes within these loopsneural processes within these loops

• Damage often upsets balance/homeostasis in a processDamage often upsets balance/homeostasis in a process

• A “normal” process runs unchecked or fails to run at allA “normal” process runs unchecked or fails to run at all

• Like other neurologic symptoms, many neurocognitive Like other neurologic symptoms, many neurocognitive symptoms can be thought of in “hyper” and “hypo” termssymptoms can be thought of in “hyper” and “hypo” terms• Ex: muscle tone, reflexes, basal gangliaEx: muscle tone, reflexes, basal ganglia

Principles of Organization

Where to Begin?

• Left vs. RightLeft vs. Right

• Anterior vs. PosteriorAnterior vs. Posterior

• Hierarchical ProcessingHierarchical Processing

• Cortical vs. SubcorticalCortical vs. Subcortical

Hemispheric Specialization


•Don’t think in terms of hemispheric “dominance”Don’t think in terms of hemispheric “dominance”


• Left HemisphereLeft Hemisphere• SpeechSpeech• Reading/writingReading/writing• PraxisPraxis• Verbal memoryVerbal memory• Processing detailProcessing detail

• Right HemisphereRight Hemisphere• ArousalArousal• Self-awarenessSelf-awareness• Spatially directed Spatially directed

attentionattention• Emotion/affectEmotion/affect• Nonverbal memoryNonverbal memory• Visuospatial processingVisuospatial processing• Processing “gestalt”Processing “gestalt”• Nonlanguage soundNonlanguage sound• MusicMusic


• Left Hemisphere: “Classic” Clinical PresentationLeft Hemisphere: “Classic” Clinical Presentation• Right hemiparesisRight hemiparesis• AphasiaAphasia• ApraxiaApraxia


• Right Hemisphere: “Classic” Clinical PresentationRight Hemisphere: “Classic” Clinical Presentation• Left hemiparesisLeft hemiparesis• Poor arousalPoor arousal• Left neglectLeft neglect• Unawareness of deficitsUnawareness of deficits• Flat affectFlat affect

Anterior vs. Posterior


• PosteriorPosterior• Processing of information about the environmentProcessing of information about the environment• Sensory gatingSensory gating• Unimodal and multimodal sensory associationsUnimodal and multimodal sensory associations• Constructing a unified “representation” of the Constructing a unified “representation” of the

environment across sensory modalitiesenvironment across sensory modalities


• AnteriorAnterior• Planning and formulating cognitive and behavioral goalsPlanning and formulating cognitive and behavioral goals• Acting on hypothetical representations of the Acting on hypothetical representations of the

environmentenvironment• Incorporating behavioral relevance, reinforcement value, Incorporating behavioral relevance, reinforcement value,

and emotion into cognition and behaviorand emotion into cognition and behavior

Hierarchical Processing

SMASMAPremotorPremotor

PrimaryPrimary

MotorMotor

PrimaryPrimary

SomatosensorySomatosensory

UnimodalUnimodal

AssociationAssociation

Multimodal Association CortexMultimodal Association Cortex

PrimaryPrimary

VisualVisual

UnimodalUnimodal


PrimaryPrimary

AuditoryAuditory

UnimodalUnimodal


AnteriorAnterior PosteriorPosterior

Cortical vs. Subcortical

• Subcortical structuresSubcortical structures• Initiation Initiation • Cessation Cessation • Modulation Modulation • ControlControl


• ThalamusThalamus• Not just a “sensory relay”Not just a “sensory relay”• Cortico-thalamo-cortical loops modulate:Cortico-thalamo-cortical loops modulate:

• ConsciousnessConsciousness• ArousalArousal• VigilanceVigilance

• Foundation for higher attentional processesFoundation for higher attentional processes

““Cortical tone”Cortical tone”


• Basal gangliaBasal ganglia• InitiationInitiation• Cessation Cessation • MaintenanceMaintenance

• Similar role in motor and cognitive functionSimilar role in motor and cognitive function


• Cortical-Basal Ganglionic LoopsCortical-Basal Ganglionic Loops

CortexCortex

StriatumStriatum

PallidumPallidum

s. nigras. nigra

ThalamusThalamus

SMASMA

PutamenPutamen

Vl-GPiVl-GPi

Cl-SNrCl-SNr

VLoVLo

VLmVLm

MotorMotor

FEFFEF

CaudateCaudate

(body)(body)

Cdm-GPiCdm-GPi

Vl-SNrVl-SNr

VAmcVAmc

MDplMDpl

OculomotorOculomotor


CortexCortex

StriatumStriatum

PallidumPallidum

s. nigras. nigra

ThalamusThalamus

DLPFCDLPFC

dl-Caudatedl-Caudate

(head)(head)

ldm-GPildm-GPi

vl-SNrvl-SNr

VApcVApc

MDpcMDpc

DorsolateralDorsolateral

PrefrontalPrefrontal

LOFCLOFC

vm-Caudatevm-Caudate

(head)(head)

mdm-GPimdm-GPi

rm-SNrrm-SNr

VAmcVAmc

MDmcMDmc

LateralLateral

OrbitofrontalOrbitofrontal

ACAC

VSVS

rl-GPi, VPrl-GPi, VP

rd-SNrrd-SNr

pm-MDpm-MD

Anterior Anterior

CingulateCingulate


• Basal Ganglia: Motor SymptomsBasal Ganglia: Motor Symptoms• Hyperkinetic disorders (too much movement)Hyperkinetic disorders (too much movement)

• Slow writhing movementsSlow writhing movements• Quick jerking movementsQuick jerking movements• Repetitive abrupt movementsRepetitive abrupt movements

• Hypokinetic disorder (too little movement)Hypokinetic disorder (too little movement)• Difficulty initiating motor movementDifficulty initiating motor movement• Motor impersistenceMotor impersistence• RigidityRigidity• Reduced eyeblinkReduced eyeblink


• Basal Ganglia: Cognitive SymptomsBasal Ganglia: Cognitive Symptoms• ““hypercognitive”hypercognitive”

• PerseverationPerseveration• IntrusionIntrusion

• ““Hypocognitive”Hypocognitive”• Poor cognitive initiationPoor cognitive initiation• Poor recall (failure to initiate recall processes)Poor recall (failure to initiate recall processes)• Loss of cognitive set (cognitive impersistence)Loss of cognitive set (cognitive impersistence)• Diminished semantic search effectivenessDiminished semantic search effectiveness


• Basal Ganglia: Emotionally Guided BehaviorBasal Ganglia: Emotionally Guided Behavior• ““hyper” hyper”

• Obsessive-compulsive behaviorsObsessive-compulsive behaviors• Addiction, gamblingAddiction, gambling• Mania (in some disorders such as Huntington’s Disease)Mania (in some disorders such as Huntington’s Disease)• Affective LabilityAffective Lability

• ““Hypo”Hypo”• AvolitionAvolition• Flat affectFlat affect


• CerebellumCerebellumCerebrocerebellumCerebrocerebellum

CortexCortexPlanPlan

EffectorsEffectors ““Reality”Reality”

CerebellumCerebellum

FeedbackFeedback


• Cerebellar SignsCerebellar Signs• MotorMotor

• AtaxiaAtaxia• DysmetriaDysmetria

• CognitiveCognitive• ““Cognitive Ataxia”Cognitive Ataxia”• ““Dysmetria of Thought”Dysmetria of Thought”

• Emotionally Guided BehaviorEmotionally Guided Behavior• Affective labilityAffective lability• Psychiatric symptomsPsychiatric symptoms

Putting it Together…

Motor/SensoryMotor/Sensory

CognitionCognition

Common View:Common View:

Putting it Together…

SensorimotorSensorimotor CognitionCognition

EmotionallyEmotionally

Guided Guided

BehaviorBehavior

Reality:Reality:

PurposefulPurposeful

EffortfulEffortful

AutomaticAutomatic

Principles in Action:Domains of Cognition

Domains of Cognition

• Motor and Sensory Aspects of CognitionMotor and Sensory Aspects of Cognition

• LanguageLanguage

• AttentionAttention

• Executive FunctionExecutive Function

Motor and Sensory Aspects of Cognition


PrimaryPrimary

MotorMotor

Multimodal Association Multimodal Association

CortexCortex

HemiparesisHemiparesis



PrimaryPrimary

MotorMotor


CortexCortex

Akinesia, Akinesia,

Bimanual dyscoordinationBimanual dyscoordination



PrimaryPrimary

MotorMotor


CortexCortex?? ApraxiaApraxia


• Apraxia -- Apraxia -- Inability to correctly perform learned Inability to correctly perform learned skilled movements, skilled movements, notnot due to impaired basic motor due to impaired basic motor function, impaired cognition, or impaired function, impaired cognition, or impaired comprehensioncomprehension

• Lesion: Inferior parietal lobule, corpus callosum, Lesion: Inferior parietal lobule, corpus callosum, SMASMA



PrimaryPrimary

MotorMotor


CortexCortex


PrimaryPrimary

MotorMotor


CortexCortex

CorpusCorpus

CallosumCallosum??

Alien HandAlien Hand


PrimaryPrimary

VisualVisual

VisualVisual



PrimaryPrimary




PrimaryPrimary

AuditoryAuditory

AuditoryAuditory


VisualVisual

LossLossSomatosensorySomatosensory

LossLoss

AuditoryAuditory

LossLoss


PrimaryPrimary

VisualVisual

VisualVisual



PrimaryPrimary




PrimaryPrimary

AuditoryAuditory

AuditoryAuditory


?? ?? ??


• Agnosia -- Impairment of object recognition in Agnosia -- Impairment of object recognition in the presence of relatively intact basic the presence of relatively intact basic perception and languageperception and language• Visual Object Agnosia Visual Object Agnosia • Prosopagnosia (agnosia for faces)Prosopagnosia (agnosia for faces)• Tactile AgnosiaTactile Agnosia• Auditory AgnosiaAuditory Agnosia


PrimaryPrimary

VisualVisual

VisualVisual



PrimaryPrimary




PrimaryPrimary

AuditoryAuditory

AuditoryAuditory


??


• Hemispatial NeglectHemispatial Neglect

• Visuospatial Integration DeficitsVisuospatial Integration Deficits


Language

Language

Broca’sBroca’s Wernicke’sWernicke’s


CortexCortex


CortexCortex

ExpressiveExpressive

(non-fluent)(non-fluent)

ReceptiveReceptive

(fluent)(fluent)

LanguageLanguage


““Pure”Pure”

LanguageLanguage

Language



CortexCortex


CortexCortex



ReceptiveReceptive

(fluent)(fluent)

LanguageLanguage



LanguageLanguage

Language

• Wernicke’s AphasiaWernicke’s Aphasia• Fluent speech (but doesn’t make sense)Fluent speech (but doesn’t make sense)• Impaired comprehensionImpaired comprehension• Impaired repetitionImpaired repetition

• Linguistic analog to a primary sensory deficitLinguistic analog to a primary sensory deficit• Can’t decode words or associate meaningCan’t decode words or associate meaning

Language



CortexCortex


CortexCortex



ReceptiveReceptive

(fluent)(fluent)

LanguageLanguage



LanguageLanguage

Language

• Broca’s AphasiaBroca’s Aphasia• Non-fluent speechNon-fluent speech• Intact comprehensionIntact comprehension• Impaired repetitionImpaired repetition

• Linguistic analog to a primary motor deficitLinguistic analog to a primary motor deficit• Can’t produce the components of language Can’t produce the components of language

outputoutput

Language



CortexCortex


CortexCortex



ReceptiveReceptive

(fluent)(fluent)

LanguageLanguage



LanguageLanguage

Language

• Transcortical Sensory AphasiaTranscortical Sensory Aphasia• Fluent SpeechFluent Speech• Impaired comprehensionImpaired comprehension• Intact repetitionIntact repetition

• Linguistic analog to agnosiaLinguistic analog to agnosia• Can decode the word but can’t make Can decode the word but can’t make

associations to meaningassociations to meaning

Language



CortexCortex


CortexCortex



ReceptiveReceptive

(fluent)(fluent)

LanguageLanguage



LanguageLanguage

Language

• Transcortical Motor AphasiaTranscortical Motor Aphasia• Non-fluent speechNon-fluent speech• Intact ComprehensionIntact Comprehension• Intact RepetitionIntact Repetition

• Linguistic Analog to an ApraxiaLinguistic Analog to an Apraxia• Broca’s area can produce speech, but lacks Broca’s area can produce speech, but lacks

associations necessary to assemble the associations necessary to assemble the componentscomponents

Attention

• ““Attention” is a generic termAttention” is a generic term• Refers to a family of processes Refers to a family of processes • Attention is fluid and constantly changingAttention is fluid and constantly changing

Attention

“ “Anything short of omnipresence creates the Anything short of omnipresence creates the need to choose which of many suitable need to choose which of many suitable internal and external events will be granted internal and external events will be granted access to narrow portals of consciousness access to narrow portals of consciousness and action” and action”

-- M. Mesalum-- M. Mesalum

Attention

• Aspects of AttentionAspects of Attention• ArousalArousal

• General level of responsivityGeneral level of responsivity

• OrientationOrientation• Realignment of sensory organsRealignment of sensory organs

• Selective AttentionSelective Attention• Processing of one stimulus over anotherProcessing of one stimulus over another

• Divided AttentionDivided Attention• Simultaneous processing of stimuliSimultaneous processing of stimuli

• Attention SpanAttention Span• Holding of information with rehearsalHolding of information with rehearsal

• ““Working Memory”Working Memory”• Mental manipulation of information in attention spanMental manipulation of information in attention span

Attention

• Modulation of attention is an “anterior” functionModulation of attention is an “anterior” function• It is mediated by cortical basal ganglionic loopsIt is mediated by cortical basal ganglionic loops

• Some attentional shifts are automaticSome attentional shifts are automatic• Some must be initiated and maintainedSome must be initiated and maintained• Salience and relevance must be balancedSalience and relevance must be balanced• Unwanted shifts must be inhibited (“stimulus pull”)Unwanted shifts must be inhibited (“stimulus pull”)

Executive Function

• Dorsolateral FrontalDorsolateral Frontal• Planning/goal formationPlanning/goal formation

• OrganizingOrganizing

• SequencingSequencing

• Set shiftingSet shifting

• Abstract thinkingAbstract thinking

• Orbital FrontalOrbital Frontal• InhibitionInhibition• Behavioral modulationBehavioral modulation• Cognitive modulationCognitive modulation• Evaluating relevance/rewardEvaluating relevance/reward

Executive Function

• Impaired initiation:Impaired initiation:• Failure to generate ideas/courses of actionFailure to generate ideas/courses of action

• Impaired inhibition:Impaired inhibition:• Impulsive cognitive approachImpulsive cognitive approach• You think it, you do itYou think it, you do it• You think it, you say itYou think it, you say it

Executive Function

• Impaired set-shiftingImpaired set-shifting• Perseveration/decreased mental flexibilityPerseveration/decreased mental flexibility• Inability to shift to a more appropriate strategy when you get Inability to shift to a more appropriate strategy when you get

feedback that the current strategy is ineffectivefeedback that the current strategy is ineffective

• Impaired PlanningImpaired Planning• Difficulty sequencing multiple actions to achieve a goalDifficulty sequencing multiple actions to achieve a goal• Difficulty seeing more than one “move” ahead in the gameDifficulty seeing more than one “move” ahead in the game• Difficulty generating multiple “if-then” alternate courses of actionDifficulty generating multiple “if-then” alternate courses of action• Difficulty assessing consequences of various choicesDifficulty assessing consequences of various choices

Executive Function

• Impaired Abstract ReasoningImpaired Abstract Reasoning• Literal or “concrete” thinking styleLiteral or “concrete” thinking style• More likely to think in terms of objects and actions rather More likely to think in terms of objects and actions rather

than concepts than concepts

Executive Function

• Executive Function is also…Executive Function is also…• ““Personality”Personality”• Point of convergence for cognitive, emotional, Point of convergence for cognitive, emotional,

and motivational aspects of behaviorand motivational aspects of behavior

Tune in next week…

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Higher Cognition James H. Baños, Ph.D. Department of Physical Medicine and Rehabilitation