Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature

Thirty-three women diagnosed as suffering from vulvar vestibulitis syndrome, marked by a significant history of long-term moderate to severe chronic introital dyspareunia and tenderness of the vulvar vestibule, were selected for treatment. Patients were given a computerized electromyographic evaluation of the pelvic floor muscles and were then provided with portable electromyographic biofeedback instrumentation and instructions on the conduct of daily, at-home, biofeedback-assisted pelvic floor muscle rehabilitation exercises. They received intermittent evaluations of pelvic floor muscles to ensure compliance and monitor their progress and symptom changes. The results show that after an average of 16 weeks of practice, pelvic floor muscle contractions increased 95.4%, resting tension levels decreased 68%, and the instability of the muscle at rest decreased by 62%. Subjective reports of pain decreased an average of 83%. Twenty-eight patients had abstained from intercourse for an average of 13 months. Twenty-two of these 28 patients resumed intercourse by the end of the treatment period. Six month follow-up indicated maintenance of therapeutic benefits.

Ettlinger revisited: the relation between agnosia and sensory impairment

The concept of agnosia as a higher order functional impairment, which can occur in the absence of low level visual perceptual deficits, continues to provoke debate. This controversy is complicated by the fact that, on close examination, agnosic patients do tend to have some perceptual difficulties. Thus the issue centres around the question as to whether these deficits play a causal part in the aetiology of agnosia or whether they are functionally independent, with both impairments resulting from the substantial cerebral lesions involved in agnosia. In 1956, Ettlinger published a study in which he compared the performance of patients with visual recognition deficits and patients with posterior brain lesions whose recognition abilities were intact. He argued that visual perceptual problems could not explain the recognition deficit in agnosia as he saw far worse perceptual impairments in patients who did not experience any problems in visual recognition. Although the logic of Ettlinger's argument is not disputed, some criticisms have arisen concerning the study, such as the fact that his experimental group did not include a truly object agnosic patient. In addition, Ettlinger's visual-sensory assessment can no longer be considered comprehensive in the light of present day knowledge of the cerebral visual apparatus. This study therefore investigated three (prosop)agnosic patients and five patients with unilateral brain lesions without recognition deficits on an extensive battery of visual sensory tests. The results support Ettlinger's original claim that (in some cases) agnosia cannot be explained as resulting from lower level visual impairments.

Face processing impairments after amygdalotomy

We report an investigation of face processing impairments in D.R., a 51-year-old woman with a partial bilateral amygdalotomy. D.R. was able to recognize pre-operatively familiar faces, but she showed generalized problems of name retrieval and a more circumscribed deficit affecting the recognition of faces learnt post-operatively. In contrast to her poor memory for new faces, D.R.'s ability to match simultaneously presented photographs of unfamiliar faces was unimpaired. However, D.R. also experienced deficits in expression processing which compromised the recognition of emotion from people's faces: she was poor both at matching and at identifying photographs of emotional facial expressions. In addition, her interpretation of eye gaze direction was defective, showing a more general problem in reading social signals from the face. The presence of impairments affecting the learning of new faces and the comprehension of gaze direction and facial expressions of emotion is consistent with the hypothesis of a role for the amygdala in learning and social behaviour.

Movement, face processing and schizophrenia: evidence of a differential deficit in expression analysis

Three dynamic face-processing tasks based on the Bruce & Young (1986) functional model of face processing were presented to 10 schizophrenic and 10 depressed inpatients and to 10 non-patient subjects. Familiar face recognition, facial expression recognition and unfamiliar face matching were examined. Schizophrenic patients' performance was significantly poorer than that of depressed patients and non-patient controls. Significantly lower scores were obtained on the facial expression recognition task than on the familiar face recognition task. There was a differential pattern of group performance on each of the three tasks: schizophrenic and depressed patients were as accurate as non-patient controls on the familiar face recognition task, but significantly less accurate than non-patient controls on the unfamiliar face-matching task. Schizophrenic patients were significantly less accurate than depressed patients and non-patient controls on the facial expression recognition task. The results are contrasted with an analogous static face-processing study.

The nature of semantic priming effects in the recognition of familiar people

We report a series of experiments examining the nature of semantic priming effects in the recognition of familiar people. Experiment 1 showed that facilitation of the recognition of familiar target faces by related face primes occurs within the recognition system, since there is no equivalent priming when subjects are asked only to determine the sex of the target faces, rather than to recognize them as familiar. Experiments 2 and 3 examined the basis of the facilitatory effect of related primes, and showed that both for familiarity decision (Expt 2 and Expt 3) and face naming (Expt 3) tasks it is primarily based on close association of the prime and target people, rather than common membership of a semantic category. This associative component of semantic priming was further explored in Expt 4, which showed that cross-domain priming from face primes to target names was present for associated prime-target pairs, but was maximal when prime and target were the face (prime) and name (target) of the same person. The results of the experiments are consistent with the interactive activation simulation developed by Burton, Bruce & Johnston (1990), and set constraints which will have to be met by any other plausible account of semantic priming.

Recognition impairments and face imagery

We investigated face imagery for H.J.A. and P.H., who experience profound difficulties in recognising familiar faces. H.J.A.'s problems involve a perceptual impairment that compromises the integration of features into a coherent representation, and he does not show covert recognition of faces in indirect tests. In contrast, P.H. has shown extensive covert recognition effects, leading to the suggestion that his deficit occurs at a higher level of visual processing than H.J.A.'s. H.J.A. and P.H. were given tasks intended to explore their ability to answer questions that depended on imaging single faces, and on configuration-based or feature-based comparisons of imaged sets of three faces. For all of these face imagery tasks, P.H.'s overall performance was severely impaired. H.J.A., though, showed preserved face imagery when imaging single faces and when making feature-based comparisons between imaged faces. However, when configuration-based comparisons were demanded H.J.A. also showed a severe and stable impairment of face imagery. These observations are inconsistent with the idea that face recognition impairments have a unitary underlying cause and vary only in severity. Instead, they imply multi-stage causation, with the nature of consequent impairments of face imagery being determined by the level at which the recognition deficit arises.

Reduplication of visual stimuli

Investigation of P.T., a man who experienced reduplicative delusions, revealed significant impairments on tests of recognition memory for faces and understanding of emotional facial expressions. On formal tests of his recognition abilities, P.T. showed reduplication to familiar faces, buildings, and written names, but not to familiar voices. Reduplication may therefore have been a genuinely visual problem in P.T.'s case, since it was not found to auditory stimuli. This is consistent with hypotheses which propose that the basis of reduplication can lie in part in malfunction of the visual system.

The Capgras and Cotard delusions

We explore the relation between the Capgras delusion (the belief that your relatives have been replaced by impostors) and the Cotard delusion (the delusional belief that you have died). At first sight, these delusions would seem to have little to do with each other, except that they both involve bizarre claims about existence (for self or others). On closer examination, however, there are other parallels. Here, we summarise similarities in associated impairments of face perception, and argue that both delusions reflect an interaction of impairments at two levels. One set of contributory factors involves perceptual impairment, or anomalous perceptual experience. The other factors lead to an incorrect interpretation of this, for which we offer an explanation in terms of attribution theory. Although the Capgras and Cotard delusions are phenomenally distinct, they may therefore represent attempts to make sense of fundamentally similar experiences.

Repetition priming and proper name processing. Do common names and proper names prime each other?

Three experiments are reported in which a repetition priming technique was used to investigate whether recognition of a person's surname which is also a known word (e.g. Baker) activates the lexical representation that mediates word recognition. Experiment 1 showed that a familiarity decision to familiar full names produced an effect of repetition priming on subsequent lexical decision to words that were presented in the initial task as surnames. Experiment 2 demonstrated that, conversely, a lexical decision primed subsequent familiarity decision to full names involving the same word. Experiment 3 showed that repeating the same decision during the initial and test phases did not produce a larger repetition priming effect than that obtained when the task at test differed from the prime task (name familiarity decision vs lexical decision or vice versa). The results are interpreted as support for the view that repetition priming is due to repeated activation of representations that are accessed by both common names and proper names.

Sequential Cotard and Capgras delusions

We report sequential Cotard and Capgras delusions in the same patient, KH, and offer a simple hypothesis to account for this link. The Cotard delusion occurred when KH was depressed and the Capgras delusion arose in the context of persecutory delusions. We suggest that the Cotard and Capgras delusions reflect different interpretations of similar anomalous experiences, and that the persecutory delusions and suspiciousness that are often noted in Capgras cases contribute to the patients' mistaking a change in themselves for a change in others ('they are impostors'), whereas people who are depressed exaggerate the negative effects of the same change whilst correctly attributing it to themselves ('I am dead'). This explains why there might be an underlying similarity between delusions which are phenomenally distinct.

Face perception after brain injury. Selective impairments affecting identity and expression

Current theoretical models of face perception postulate separate routes for processing information needed in the recognition of a familiar face, for matching photographs of unfamiliar faces and for the analysis of facial expressions. The present study investigated this claim in a group of ex-servicemen who had sustained unilateral brain injuries affecting posterior areas of the left or right cerebral hemisphere. Care was taken to confirm the nature of impairment by using two different tasks to assess each of the three theoretically defined abilities (leading to a total of six tasks). We adopted a stringent application of the double dissociation methodology to investigate the pattern of performance across tasks of individual ex-servicemen. A selective impairment was defined as a significantly impoverished performance on both tests of a specific ability, while all other tasks were performed within normal limits. In addition, we used both accuracy and response latency measures to substantiate evidence for spared or defective abilities. The results showed selective impairments of all three abilities on accuracy scores. Response latency data confirmed the finding of a selective deficit in the processing of facial expressions, but produced evidence suggesting that impairments affecting familiar face recognition and unfamiliar face matching were not completely independent from each other in this group of ex-servicemen.

Face-processing impairments and the Capgras delusion

Investigations of two cases of the Capgras delusion found that both patients showed face-processing impairments encompassing identification of familiar faces, recognition of emotional facial expressions, and matching of unfamiliar faces. In neither case was there any impairment of recognition memory for words. These findings are consistent with the idea that the basis of the Capgras delusion lies in damage to neuro-anatomical pathways responsible for appropriate emotional reactions to familiar visual stimuli. The delusion would then represent the patient's attempt to make sense of the fact that these visual stimuli no longer have appropriate affective significance.

Frégoli delusion and erotomania

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Impaired discrimination of familiar from unfamiliar faces

We report investigations of the face processing abilities of J.T., a man who had suffered a right hemisphere stroke. J.T. showed a marked problem in discriminating between familiar and unfamiliar faces, with no corresponding problem in discriminating familiar from unfamiliar names. The problem with faces was still found 2 years after the stroke, but had resolved at long-term follow-up (9 years post stroke). When given unlimited time to respond, J.T. did not show any problem in recognising familiar faces, but tended to think that he recognised unfamiliar faces. When under time pressure, however, J.T. also failed to recognise a number of familiar faces which he could readily identify when the time pressure was removed. J.T.'s ability to remember a face and to think of other people who might be similar in appearance was affected by whether or not the face seemed familiar or unfamiliar to him. Hence, whatever underlay the spurious sense of familiarity was sufficient to produce real differences between the way in which genuinely unfamiliar and spuriously familiar faces were seen, leading us to suggest that his impaired discrimination of unfamiliar from familiar faces reflected a malfunction of face recognition units.

Pseudopelade of Brocq is lichen planopilaris: report of four cases that support this nosology

Four patients are presented with pseudopelade of Brocq whose symptoms also illustrate the spectrum of symptoms of lichen planus. The literature is reviewed and the clinical and histologic features of pseudopelade of Brocq and lichen planopilaris are described. The literature on pseudopelade of Brocq is confusing and outdated. Since Degos's article in 1954, it has become commonly accepted that pseudopelade of Brocq is a nonspecific cicatricial end stage of scalp diseases resulting in alopecia. We maintain instead that pseudopelade of Brocq and lichen planopilaris are basically the same condition, namely a manifestation of lichen planus.

Voice recognition impairment in a blind Capgras patient

We report a case of a blind woman, M.N., who experienced the Capgras delusion. She thought that her pet cat had been replaced by a replica which was "ill-intentioned" towards her. M.N.'s case shows that the basis of the Capgras delusion cannot lie exclusively in damage to the visual system. However, testing of M.N.'s auditory recognition abilities revealed a deficit in the recognition of familiar voices. This impairment is consistent with the view that the Capgras delusion may arise in connection with damage to recognition mechanisms, and parallels findings of face processing impairments in sighted Capgras patients.

Cotard delusion after brain injury

A right-handed young man with contusions affecting temporo-parietal areas of the right cerebral hemisphere and some bilateral frontal lobe damage became convinced that he was dead (the Cotard delusion), and experienced difficulties in recognizing familiar faces, buildings and places, as well as feelings of derealization. Neuropsychological investigation while these symptoms were resolving revealed impairment on face processing tests. We suggest that these impairments contributed to his Cotard delusion by heightening feelings of unreality, and that the underlying pathophysiology and neuropsychology of the Cotard delusion may be related to other problems involving delusional misidentification.

Repetition priming follows spontaneous but not prompted recognition of familiar faces

Reaction times to make a familiarity decision to the faces of famous people were measured after recognition of the faces in a pre-training phase had occurred spontaneously or following prompting with a name or other cue. At test, reaction times to familiar faces that had been recognized spontaneously in the pre-training phase were significantly facilitated relative to an unprimed comparison condition. Reaction times to familiar faces recognized only after prompting in the pre-training phase were not significantly facilitated. This was demonstrated both when a name prompt was used (Experiments 1 and 3) and when subjects were cued with brief semantic information (Experiment 2). Repetition priming was not found to depend on prior spontaneous recognition per se. In Experiment 3, spontaneously recognizing a familiar face did not prime subsequent familiarity judgements when the same face had only been identified following prompting on a prior encounter. In Experiment 4, recognition memory for faces recognized after cueing was found to be over 90% accurate. This indicates that prompted recognition does not yield repetition priming, even though subjects can remember the faces. A fusion of "face recognition unit" and "episodic record" accounts of the repetition priming effect may be more useful than either theory alone in explaining these results.

Face processing in psychiatric conditions

Functional models of face processing have indicated that dissociations exist between the various processes involved, e.g. between familiar face recognition and matching of unfamiliar faces, and between familiar face recognition and facial expression analysis. These models have been successfully applied to the understanding of the different types of impairment that can exist in neuropsychological patients. In the present study, aspects of face processing in psychiatric patients were investigated in relation to Bruce & Young's (1986) model. Based on this functional model different predictions can be made. We contrast here the impaired expression analysis hypothesis, which is that psychiatric patients would show a deficit in facial expression recognition, but not in facial identity recognition or unfamiliar face matching, with the generalized deficit hypothesis, that patients would be impaired on all tasks. These hypotheses were examined using three forced-choice tasks (facial recognition, facial expression recognition, and unfamiliar face matching) which were presented to schizophrenic and depressed patients, and to non-patient controls. Results showed that schizophrenic patients performed at a significantly lower level than non-patient controls on all three tasks, supporting the generalized deficit hypothesis.

Neglect and visual recognition

B.Q., a right-handed woman who had suffered a stroke affecting the right parietal region, showed visuospatial neglect and problems in recognizing seen objects and faces. Investigation of her visual recognition problems revealed a striking inability to identify the left sides of chimaeric objects and faces. Often, B.Q. would deny that the stimulus was chimaeric at all, and she was remarkably poor (though above chance) at discriminating chimaeric from normal faces. Even when left-sided details had been accurately traced or described, they were often either ignored in reporting the identities of the constituent parts of a chimaeric or assimilated in some way to the information from the right side. Neglect of the left side was more pronounced for chimaerics which approximated an individual face or object. It occurred regardless of the chimaeric's position in B.Q.'s field of vision, and was found with brief (200 ms) presentations of stimuli confined to her (perimetrically intact) right visual field. When chimaeric faces were inverted, B.Q. continued to neglect the side of the chimaeric falling to her left, which implies that the neglect did not operate in entirely object-centered coordinates. However, left-sided information could be used if it was critical in determining the identity of an object or a face. We suggest that this could explain B.Q.'s lack of neglect of individual words, for which left-sided (initial) letters are often crucial to successful recognition. An account of her deficit is proposed, involving an interaction between moderately defective pick-up of left-sided information in an object-based coding system and preserved access to stored representations of familiar visual stimuli.

Neuropsychological impairment of face recognition units

Despite the absence of "conscious", overt identification, some patients with face recognition impairments continue covertly to process information regarding face familiarity. The fact that by no means all patients show these covert effects has led to the suggestion that indirect recognition tasks may help in identifying different types of face recognition impairment. The present report describes a number of experiments with the patient NR, who, after a closed head injury, has been severely impaired at recognizing familiar faces. Investigations mostly failed to show overt or covert face recognition, but NR performed at an above-chance level in selecting the familiar face on a task requiring a forced-choice between a familiar and an unfamiliar face. This discrepancy between a degree of rudimentary overt recognition and absence of covert effects on most indirect tests was addressed using a cross-domain identity priming paradigm. This examined separately the possibility of preserved recognition for faces that NR consistently chose correctly in a forced-choice familiarity decision and those on which he performed at chance level. Priming effects were apparent only for the faces that were consistently chosen as "familiar" in forced-choice. We suggest that NR's stored representations of familiar faces are degraded, so that face recognition is possible only via a limited set of relatively preserved representations able to support a rudimentary form of overt recognition and to facilitate performance in matching and priming tasks.

Priming of face matching in amnesia

Priming was studied in a task that required a speeded response to photographs of faces. On each trial, subjects viewed two faces and decided if the same person was shown twice or if two different people were shown. Both familiar and unfamiliar (i.e., well-known and unknown) faces were used, and some face pairs were repeated with a mean delay of about 10 min. Repetition was associated with faster reaction times in young subjects (Experiment 1) as well as in amnesic patients and age-matched control subjects (Experiment 2). The patients' reaction times were slower overall, although the magnitude of the priming effect did not differ from that in the control subjects. This preservation of a normal reaction-time facilitation in subjects with impaired recognition memory for faces occurred for both familiar and unfamiliar faces, suggesting that amnesia does not necessarily interfere with the acquisition of new information as indexed by this priming effect.

Covert and overt recognition in prosopagnosia

Prosopagnosic patients suffer an inability to recognize familiar people by visual inspection of their faces. Despite the absence of overt recognition, though, some prosopagnosic patients continue to process the identities of familiar faces covertly. A longstanding controversy concerns whether the recognition deficit in prosopagnosia is specific for faces, or also affects other types of visual stimuli. We investigated whether the patient P.H., who has severe problems with within-class recognition of many types of visual stimuli, would show covert recognition for all stimuli which he cannot recognize overtly. Such a finding would be consistent with the idea that face recognition and recognition of other visually similar stimuli are performed by the same underlying functional mechanisms. We assessed this possibility with a forced-choice decision between correct and incorrect alternative names for familiar faces, cars and flowers, and with comparisons of P.H.'s ability to learn true versus untrue names to familiar faces, cars and flowers. Results indicated that P.H. does show covert recognition of cars and flowers, as well as faces. In addition, the covert effects observed in the forced-choice name decision and learning tasks used here were shown to have a potential common basis. Finally, the possibility of using covert knowledge as a basis for rehabilitation was explored. As was observed by Sergent and Poncet (1990) in their patient, P.H. could achieve some overt face recognition under very specific circumstances.

Routes through the face recognition system

Two experiments are reported which seek to examine the proposition first put forward by Hay and Young (1982), that recognition of a known person after seeing his or her face proceeds through a series of sequentially organized stages. In both experiments subjects were shown a selection of famous and unfamiliar faces and required to state whether each face was familiar. They were then asked to recall semantic information and the person's name. Of all the possible response types, only some are predicted by models derived from Hay and Young (1982), and only these responses were observed in Experiment 1. In order to give as complete an account as possible of the slips and errors made by subjects, they were interrogated some days after completing the testing phase in Experiment 2. As in the first experiment, the results supported the view that distinct but successive stages are involved in everyday face recognition. The method developed here provides an extension of the "dairy" type of study of everyday recognition errors into laboratory conditions, which confirms the findings of studies of everyday errors and provides strong support for sequential models.

Dissociable face processing impairments after brain injury

Matched populations of head-injured patients and normal control subjects completed three "forced-choice" face processing tasks designed to test facial expression recognition, familiar face recognition, and unfamiliar face matching. We hypothesised a significant difference in the performance of the patients and controls on the three tasks, and hoped to observe individual differences in the patients' performance across tasks. As predicted the head-injured patients made significantly more errors than the controls on the forced-choice tasks. Four cases of dissociable impairments affecting only one of the face processing tasks are reported; patient JP impaired only on facial expression recognition, patients AB and HI impaired only on familiar face recognition, and patient VS impaired only on unfamiliar face matching. These dissociable impairments provide further evidence for independent cognitive processing of specific face properties.