Motor Awareness Research Articles

Augmenting locomotor perception by remapping tactile foot sensation to the back

BackgroundSensory reafferents are crucial to correct our posture and movements, both reflexively and in a cognitively driven manner. They are also integral to developing and maintaining a sense of agency for our actions. In cases of compromised reafferents, such as for persons with amputated or congenitally missing limbs, or diseases of the peripheral and central nervous systems, augmented sensory feedback therefore has the potential for a strong, neurorehabilitative impact. We here developed an untethered vibrotactile garment that provides walking-related sensory feedback remapped non-invasively to the wearer’s back. Using the so-called FeetBack system, we investigated if healthy individuals perceive synchronous remapped feedback as corresponding to their own movement (motor awareness) and how temporal delays in tactile locomotor feedback affect both motor awareness and walking characteristics (adaptation).MethodsWe designed the system to remap somatosensory information from the foot-soles of healthy participants (N = 29), using vibrotactile apparent movement, to two linear arrays of vibrators mounted ipsilaterally on the back. This mimics the translation of the centre-of-mass over each foot during stance-phase. The intervention included trials with real-time or delayed feedback, resulting in a total of 120 trials and approximately 750 step-cycles, i.e. 1500 steps, per participant. Based on previous work, experimental delays ranged from 0ms to 1500ms to include up to a full step-cycle (baseline stride-time: µ = 1144 ± 9ms, range 986-1379ms). After each trial participants were asked to report their motor awareness.ResultsParticipants reported high correspondence between their movement and the remapped feedback for real-time trials (85 ± 3%, µ ± σ), and lowest correspondence for trials with left-right reversed feedback (22 ± 6% at 600ms delay). Participants further reported high correspondence of trials delayed by a full gait-cycle (78 ± 4% at 1200ms delay), such that the modulation of motor awareness is best expressed as a sinusoidal relationship reflecting the phase-shifts between actual and remapped tactile feedback (cos model: 38% reduction of residual sum of squares (RSS) compared to linear fit, p < 0.001). The temporal delay systematically but only moderately modulated participant stride-time in a sinusoidal fashion (3% reduction of RSS compared a linear fit, p < 0.01).ConclusionsWe here demonstrate that lateralized, remapped haptic feedback modulates motor awareness in a systematic, gait-cycle dependent manner. Based on this approach, the FeetBack system was used to provide augmented sensory information pertinent to the user’s on-going movement such that they reported high motor awareness for (re)synchronized feedback of their movements. While motor adaptation was limited in the current cohort of healthy participants, the next step will be to evaluate if individuals with a compromised peripheral nervous system, as well as those with conditions of the central nervous system such as Parkinson’s Disease, may benefit from the FeetBack system, both for maintaining a sense of agency over their movements as well as for systematic gait-adaptation in response to the remapped, self-paced, rhythmic feedback.

Convergence of visual and motor awareness in human parietal cortex.

Brain lesions sometimes induce a failure of recognition of one's own deficits (anosognosia). Lack of deficit awareness may underlie damage of modality-specific systems, e.g., visual cortex for visual anosognosia or motor/premotor cortex for motor anosognosia. However, focal lesions induce widespread remote structural and functional disconnection, and anosognosia, independent of modality, may also involve common neural mechanisms. Here, we study the neural correlates of Anton syndrome (AS), anosognosia of blindness, and compare them with anosognosia for hemiplegia to test if they share different or common mechanisms. We measured both local damage and patterns of structural-functional disconnection as predicted from healthy normative atlases. AS depends on bilateral striate and extra-striate occipital damage, and disconnection of ventral and dorsal frontoparietal regions involved in attention control. Visual and motor anosognosia each share damage of modality-specific regions, but also involve the disruption of white matter tracts leading to functional disconnection within dorsal frontal-parietal regions that play critical roles in motor control, visuospatial attention, and multi-sensory integration. These results reveal the unique shared combination of content-specific and supra-modal mechanisms in anosognosia. This article is protected by copyright. All rights reserved.

Modulation of Motor Awareness: A Transcranial Magnetic Stimulation Study in the Healthy Brain.

Previous studies on the mechanisms underlying willed actions reported that the premotor cortex may be involved in the construction of motor awareness. However, its exact role is still under investigation. Here, we investigated the role of the dorsal premotor cortex (PMd) in motor awareness by modulating its activity applying inhibitory rTMS to PMd, before a specific motor awareness task (under three conditions: without stimulation, after rTMS and after Sham stimulation). During the task, subjects had to trace straight lines to a given target, receiving visual feedback of the line trajectories on a computer screen. Crucially, in most trials, the trajectories on the screen were deviated, and to produce straight lines, subjects had to correct their movements towards the opposite direction. After each trial, participants were asked to judge whether the line seen on the computer screen corresponded to the line actually drawn. Results show that participants in the No Stimulation condition did not recognize the perturbation until 14 degrees of deviation. Importantly, active, but not Sham, rTMS significantly modulated motor awareness, decreasing the amplitude of the angle at which participants became aware of the trajectory correction. These results suggest that PMd plays a crucial role in action self-monitoring.

Motor awareness: a model based on neurological syndromes.

Motor awareness is a complex, multifaceted construct involving the awareness of both (i) one's motor state while executing a movement or remaining still and (ii) one's motor abilities. The analysis of neurological syndromes associated with motor disorders suggests the existence of various different components which are, however, integrated into a model of motor awareness. These components are: (i) motor intention, namely, a conscious desire to perform an action; (ii) motor monitoring and error recognition, that is, the capacity to check the execution of the action and identify motor errors; and (iii) a general awareness of one's own motor abilities and deficits, that is, the capacity to recognize the general state of one's motor abilities about the performance of specific actions and the potential consequences of motor impairment. Neuroanatomical correlates involving the parietal and insular cortices, the medial and lateral frontal regions, and subcortical structures (basal ganglia and limbic system) support this multi-component model. Specific damage (or disconnections) to these structures results in a number of different disorders in motor awareness, such as anosognosia for hemiplegia and apraxia, and a number of symptoms which are specific to motor intention disorders (e.g., the Anarchic Hand Syndrome and Tourette's Syndrome) or motor monitoring (e.g., Parkinson's and Huntington's diseases). All of these clinical conditions are discussed in the light of a motor awareness model.

Active inference unifies intentional and conflict-resolution imperatives of motor control.

The field of motor control has long focused on the achievement of external goals through action (e.g., reaching and grasping objects). However, recent studies in conditions of multisensory conflict, such as when a subject experiences the rubber hand illusion or embodies an avatar in virtual reality, reveal the presence of unconscious movements that are not goal-directed, but rather aim at resolving multisensory conflicts; for example, by aligning the position of a person’s arm with that of an embodied avatar. This second, conflict-resolution imperative of movement control did not emerge in classical studies of motor adaptation and online corrections, which did not allow movements to reduce the conflicts; and has been largely ignored so far in formal theories. Here, we propose a model of movement control grounded in the theory of active inference that integrates intentional and conflict-resolution imperatives. We present three simulations showing that the active inference model is able to characterize movements guided by the intention to achieve an external goal, by the necessity to resolve multisensory conflict, or both. Furthermore, our simulations reveal a fundamental difference between the (active) inference underlying intentional and conflict-resolution imperatives by showing that it is driven by two different (model and sensory) kinds of prediction errors. Finally, our simulations show that when movement is only guided by conflict resolution, the model incorrectly infers that is velocity is zero, as if it was not moving. This result suggests a novel speculative explanation for the fact that people are unaware of their subtle compensatory movements to avoid multisensory conflict. Furthermore, it can potentially help shed light on deficits of motor awareness that arise in psychopathological conditions.

Dissociation of motor control from motor awareness in awake sleepwalkers: An EEG study in virtual reality

Recent behavioral evidence from a virtual reality (VR) study indicates that awake sleepwalkers show dissociation of motor control and motor awareness. This dissociation resembles the nocturnal disintegration of motor awareness and movement during episodes of sleepwalking. Here, we set out to examine the neural underpinnings of altered motor awareness in sleepwalkers by measuring EEG modulation during redirected walking in VR. To this end, we measured scalp EEG during ongoing motor behavior to provide information on motor processing and its modulation in VR. Using this approach, we discovered distinct EEG patterns associated to dual tasking and sub-threshold motor control in sleepwalkers compared to control subjects. These observations provide further electrophysiological evidence for the proposed brain-body dissociation in awake sleepwalkers.This study shows proof-of-principle that EEG biomarkers of movement in a VR setting add to the understanding of altered motor awareness in sleepwalkers. In a broader perspective, we confirm the feasibility of using the additional dimensionality in VR providing novel diagnostic biomarkers not accessible to conventional clinical investigations. In future studies, this approach could contribute to the diagnostic work-up of patients with a broad spectrum of neurological diseases.

The sense of agency in joint actions: A theory-driven meta-analysis

The sense of agency is the feeling of voluntarily controlling our actions and their effects. It represents a crucial component of self-awareness, and it is foundational to our perception of responsibility toward what we do as individuals acting in a social context. While the sense of agency has been widely investigated in individual contexts, much less is known about the agency experienced when subjects are involved in motor interactions, despite its relevance in the social domain. To fill this gap, here we review the literature on the sense of agency experienced during motor interactions. We aimed to test the reliability of this sense of joint agency across studies and define what features can modulate its explicit and implicit components. To this end, we performed a formal meta-analysis of studies investigating the implicit feeling of agency in joint actions and a systematic review of studies addressing explicit judgments of agency during motor interactions. Our review indicates that, during interactions, a sense of agency can also be experienced for the partner's actions, both at an implicit and explicit level, and that this possibility strongly depends on predictive sensorimotor mechanisms. Contextual cues play a crucial role too, but mainly on explicit agency judgments, while they do not affect the implicit feeling of agency. These results are discussed in light of current cognitive theories on motor awareness and motor interactions. We also propose a hierarchical model based on recursive predictive and comparative processes whereby the sense of joint agency is grounded on a weighted combination of sensorimotor and contextual cues. Finally, we discuss how this model may provide a framework for future research in the social and clinical domains.

The Motor Unawareness Assessment (MUNA): A new tool for the assessment of Anosognosia for hemiplegia

ABSTRACT Introduction: Anosognosia for hemiplegia (AHP) is a condition in which patients with paralysis are unaware of their motor deficits. Research into AHP is important for improving its treatment and providing insight into the neurocognitive mechanism of motor awareness. Unfortunately, most studies use assessments with widely recognized limitations. The study aims at developing a psychometrically validated assessment of AHP. Method: We developed a 40-item Motor Unawareness Assessment (MUNA) and administered it to 131 right-hemisphere stroke patients. Principal Component Analysis (PCA) was used to identify the underlying factor structure. Receiver Operating Characteristics (ROC) analysis was used to determine diagnostic cutoffs, and Area Under the Curve (AUC) analysis used to assess these cutoffs. Relationships with demographic, clinical and neuropsychological variables were explored. Results: Five factors were identified: explicit motor awareness, implicit motor awareness, impaired sense of ownership, agency and illusory movement, and emotional reactions. Established cutoffs had excellent sensitivity and specificity. Clinical, neuropsychological and demographic variables did not predict overall MUNA score but were related to specific subcomponents. Conclusion: The MUNA can differentiate various facets of AHP and provides a detailed profile of (un)awareness. The MUNA can therefore provide robust assessment for research purposes and assist clinicians when developing targeted rehabilitation.

Gait-phase-dependent and gait-phase-independent cortical activity across multiple regions involved in voluntary gait modifications in humans.

Modification of ongoing walking movement to fit changes in external environments requires accurate voluntary control. In cats, the motor and posterior parietal cortices have crucial roles for precisely adjusting limb trajectory during walking. In human walking, however, it remains unclear which cortical information contributes to voluntary gait modification. In this study, we investigated cortical activity changes associated with visually guided precision stepping using electroencephalography source analysis. Our results demonstrated frequency- and gait-event-dependent changes in the cortical power spectrum elicited by voluntary gait modification. The main differences between normal walking and precision stepping were as follows: (a) the alpha, beta or gamma power decrease during the swing phases in the sensorimotor, anterior cingulate and parieto-occipital cortices, and (b) a power decrease in the theta, alpha and beta bands and increase in the gamma band throughout the gait cycle in the parieto-occipital cortex. Based on the previous knowledge of brain functions, the former change was considered to be related to execution and planning of leg movement, while the latter change was considered to be related to multisensory integration and motor awareness. Therefore, our results suggest that the gait modification is achieved by higher cortical involvements associated with different sensorimotor-related functions across multiple cortical regions including the sensorimotor, anterior cingulate and parieto-occipital cortices. The results imply the critical importance of the cortical contribution to voluntary modification in human locomotion. Further, the observed cortical information related to voluntary gait modification would contribute to developing volitional control systems of brain-machine interfaces for walking rehabilitation.

Direct electrical stimulation of the premotor cortex shuts down awareness of voluntary actions

A challenge for neuroscience is to understand the conscious and unconscious processes underlying construction of willed actions. We investigated the neural substrate of human motor awareness during awake brain surgery. In a first experiment, awake patients performed a voluntary hand motor task and verbally monitored their real-time performance, while different brain areas were transiently impaired by direct electrical stimulation (DES). In a second experiment, awake patients retrospectively reported their motor performance after DES. Based on anatomo-clinical evidence from motor awareness disorders following brain damage, the premotor cortex (PMC) was selected as a target area and the primary somatosensory cortex (S1) as a control area. In both experiments, DES on both PMC and S1 interrupted movement execution, but only DES on PMC dramatically altered the patients’ motor awareness, making them unconscious of the motor arrest. These findings endorse PMC as a crucial hub in the anatomo-functional network of human motor awareness.

Anosognosia for hemiplegia as a tripartite disconnection syndrome.

The syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into the neurocognitive processes of motor awareness. Yet, prior studies have only explored predominately discreet lesions. Using advanced structural neuroimaging methods in 174 patients with a right-hemisphere stroke, we were able to identify three neural systems that contribute to AHP, when disconnected or directly damaged: the (i) premotor loop (ii) limbic system, and (iii) ventral attentional network. Our results suggest that human motor awareness is contingent on the joint contribution of these three systems.

All dressed up

Mastering the skill of dressing involves fine motor skills, body awareness and co-ordination. These games deliver the fun factor and the impetus for children to become independent.

Remembering actions without proprioception

It has been suggested that agency signals generated by enactment provide memories with an enduring episodic marker that can successively be exploited to facilitate recall. Current theories of motor awareness highlight the role of prospective and retrospective sensorimotor cues in the construction of sense of agency (SA). To explore how these signals impact on memory for actions, we studied the effect of enactment in a patient with complete loss of somatic sensation below nose level, and compared her performance to that of a group of neurologically intact individuals. A memory advantage for enacted material was clearly detectable in the control group and, interestingly, also in sensory deafferented patient GL. This novel finding shows that robust memory for actions can be obtained even in the absence of somatosensory reafferences. We hypothesize that the neural processes evoked by intention to move, together with visual experience about one's actions, provide the long-lasting agency signals that are responsible for the special quality of self-performed actions and may support autobiographical experience. Proprioceptive cues, being more time-constrained, are critical to online SA but do not necessarily partake in offline action representations.

Metacognition of visuomotor decisions in conversion disorder

Motor conversion disorder (CD) entails genuine disturbances in the subjective experience of patients who maintain they are unable to perform a motor function, despite lack of apparent neurological damage. Abilities by which individuals assess their own capacities during performance in a task are called metacognitive, and distinctive impairment of such abilities is observed in several disorders of self-awareness such as blindsight and anosognosia. In CD, previous research has focused on the recruitment of motor and emotional brain systems, generally linking symptoms to altered limbic-motor interactions; however, metacognitive function has not been studied to our knowledge. Here we tested ten CD patients and ten age-gender matched controls during a visually-guided motor paradigm, previously employed in healthy controls (HC), allowing us to probe for motor awareness and metacognition. Participants had to draw straight trajectories towards a visual target while, unbeknownst to them, deviations were occasionally introduced in the reaching trajectory seen on the screen. Participants then reported both awareness of deviations and confidence in their response. Activity in premotor and cingulate cortex distinguished between conscious and unconscious movement corrections in controls better than patients. Critically, whereas controls engaged the left superior precuneus and middle temporal region during confidence judgments, CD patients recruited bilateral parahippocampal and amygdalo-hippocampal regions instead. These results reveal that distinct brain regions subserve metacognitive monitoring for HC and CD, pointing to different mechanisms and sources of information used to monitor and form confidence judgments of motor performance. While brain systems involved in sensory-motor integration and vision are more engaged in controls, CD patients may preferentially rely on memory and contextual associative processing, possibly accounting for how affect and memories can imbue current motor experience in these patients.

P248 Neuromodulation of the right premotor cortex affects motor monitoring and awareness

Introduction Motor execution, planning, and learning are altered by transcranial Direct Current Stimulation (tDCS). The potential of this technique for modulating action monitoring and awareness has not been explored so far. Optimal motor control relies on internal representations of the intended, predicted, and actual action. The brain is equipped with a “comparator” system, which monitors and detects the congruence between planned and performed movements; based on this comparison motor awareness is constructed. Objectives The study aimed at disrupting motor monitoring and awareness through the neuromodulation of the activity of the Premotor (PMC) and Posterior Parietal (PPC) cortices of the right hemisphere. Methods Real or sham cathodal tDCS (1.5 mA, 6 min) were applied over the right PMC or PPC in 22 healthy participants (8 right-handed men, mean age = 25.5 years). Before and after tDCS, participants performed a 2-digit sequence motor task and rated how well they had executed it on a 5-item questionnaire (Motor Performance Awareness Questionnaire – MPAQ). During the task performed after tDCS, online single-pulse Transcranial Magnetic Stimulation (sTMS) was applied to the right primary motor cortex (M1), contralateral to the executing left hand, with the aim of evoking involuntary muscles twitches, interfering with motor execution. Results Cathodal tDCS to PMC (but not sham tDCS or PPC tDCS) impaired motor monitoring, making participants unconfident about their explicit judgments on their motor performance (MPAQ, tDCS by Time interaction, F = 3.74, pr = .59, p = .004) and PPC (r = .69, p = .001) tDCS, but not after PMC tDCS (r = .22, p = .32). Conclusion Cathodal tDCS to the right PMC disrupts the participants’ ability to evaluate their motor performance reliably, disrupting self-confidence about own motor performance and also the ability to detect the discrepancy between their planned and performed Convento et al., 2014 , Frith et al., 2000 .

T004 Cognitive processes of motor behavior revealed by tDCS

Transcranial direct current stimulation (tDCS) is a non-invasive tool, which effectively modulates behavior, and related brain activity. When applied to the primary motor cortex (M1), tDCS affects motor function, enhancing or decreasing motor learning and action execution in both healthy participants and brain-damaged patients. Evidence in both humans and macaques has shown that multiple cortical areas beyond M1 are involved in controlling and guiding movement, including the posterior parietal cortex (PPC) and the premotor cortex (PMC). Recent evidence in healthy humans and brain-damaged showed that the modulation of cortical excitability of PPC and PMC can be used to improve action-related cognitive processes, highlighting interesting hemispheric asymmetries. Indeed, the anodal tDCS of the PPC of the left hemisphere can be used to selectively facilitate action planning and gesture recognition, while excitability shifts within the PM of the right hemisphere affects action monitoring and awareness. These results indicate that a left parietal system contributes to the activation of motor engrams (such as the pattern and sequence of movements needed to execute an action), while left premotor areas are mostly involved in the operation of the motor monitoring, namely detecting the mismatch between the actual motor output and intended action goal. The final relay is M1, which converts the motor program into the desired action. In conclusion, this evidence offers a functional and anatomical framework for understanding how selective neuromodulatory effects on different higher-level (action planning and monitoring) stages of motor processing can be induced by tDCS in order to optimize motor control and learning. This knowledge opens up novel perspectives in the neurorehabilitation of stroke patients with apraxic and motor awareness disorders, which represents a considerable burden for motor and cognitive rehabilitation.

Motor versus body awareness: Voxel-based lesion analysis in anosognosia for hemiplegia and somatoparaphrenia following right hemisphere stroke

Anosognosia for hemiplegia (AHP) is informative about the neurocognitive basis of motor awareness. However, it is frequently associated with concomitant symptoms, such as hemispatial neglect and disturbances in the sense of body ownership (DSO). Although double dissociations between these symptoms have been reported, there is ongoing debate about whether they are manifestations of independent abnormalities, or a single neurocognitive deficit. We aimed to investigate the specificity of lesions associated with AHP by surpassing four, existing methodological limitations: (a) recruit a relatively large sample of patients (total N = 70) in a multi-centre study; (b) identify lesions associated with AHP in grey and white matter using voxel-based methods; (c) take into account the duration of AHP and concomitant neglect symptoms; and (d) compare lesions against a control hemiplegic group, patients suffering from AHP and DSO, and a few, rare patients with selective DSO. Results indicated that acute AHP is associated with a wide network, mainly including: (1) the Rolandic operculum, (2) the insula and (3) the superior temporal gyri. Subcortically, damage mainly involved the basal ganglia and white matter, mostly the superior corona radiate, arcuate fasciculus and the part of the ventral, superior longitudinal fasciculus. Persistent symptoms were linked with wider damage involving fronto-temporal cortex and long white matter tracts. A shift in the latero-medial direction (mainly involving the basal ganglia and surrounding white matter) emerged when DSO was taken accounted for. These results suggest that while bodily awareness is processed by areas widely distributed across the brain, intact subcortical structures and white matter tracts may be necessary to support basic feelings of owning and controlling contralateral body parts. An accurate and ‘up-to-date’ awareness of our motor abilities, however, may rely also on intact processing in cortical areas which presumably allow higher-order inferences about the current state of the body.

Smile and laughter elicited by electrical stimulation of the frontal operculum

Laughter and smile are typical expressions of mirth and fundamental means of social communication. Despite their general interest, the current knowledge about the brain regions involved in the production of these expressions is still very limited, and the principal insights come from electrical stimulation (ES) studies in patients, in which, nevertheless, laughter or smile have been elicited very rarely. Previous studies showed that laughter is evoked by the stimulation of nodes of an emotional network encompassing the anterior cingulate, the superior frontal and basal temporal cortex. A common feature of these stimulation studies is that the facial expression was always accompanied by motor awareness and often by mirth, in line with the affective functions attributed to these regions. Little is known, in contrast, on the neural basis of the voluntary motor control of this expression. The objective of this study was to investigate the effect of ES of the frontal operculum (FO), which is considered a crucial node for the linkage of the voluntary motor system for emotional expression and limbic emotional network. We report the case of ES applied to the frontal operculum (FO) in four patients with drug-resistant focal epilepsy undergoing stereo-electroencephalographic (SEEG) implantation of intracerebral electrodes. In all patients, ES applied to the FO produced laughter or smile. Interestingly, in one patient, the production of a smiling expression was also clearly accompanied by the lack of motor awareness. Since the lack of motor awareness has been previously observed only after the stimulation of the voluntary motor network, we speculate that FO is involved in the voluntary control of facial expressions, and is placed at the interface with the emotional network, gating limbic information to the motor system.

The Effect of Intentional, Preplanned Movement on Novice Conductors’ Gesture

Preplanning movement may be one way to broaden novice conductors’ vocabulary of gesture and promote motor awareness. To test the difference between guided score study and guided score study with preplanned, intentional movement on the conducting gestures of novice conductors, undergraduate music education students ( N = 20) were assigned to one of two conditions and then evaluated on their conducting performance. The experimental group received two sessions of guided score study with planning and practicing of gestures, while the control group received two sessions of guided score study only. Participants were video recorded conducting the piece with a university instrumental ensemble and evaluated by four conducting experts on gestures of dynamics, articulation, cues, releases, and phrasing. Analysis of the mean scores for each rating revealed no significant differences between the two conditions. Analysis of postconducting interview transcriptions revealed several factors that may have contributed to the results.

Mentalizing the body: spatial and social cognition in anosognosia for hemiplegia.

Following right-hemisphere damage, a specific disorder of motor awareness can occur called anosognosia for hemiplegia, i.e. the denial of motor deficits contralateral to a brain lesion. The study of anosognosia can offer unique insights into the neurocognitive basis of awareness. Typically, however, awareness is assessed as a first person judgement and the ability of patients to think about their bodies in more 'objective' (third person) terms is not directly assessed. This may be important as right-hemisphere spatial abilities may underlie our ability to take third person perspectives. This possibility was assessed for the first time in the present study. We investigated third person perspective taking using both visuospatial and verbal tasks in right-hemisphere stroke patients with anosognosia (n = 15) and without anosognosia (n = 15), as well as neurologically healthy control subjects (n = 15). The anosognosic group performed worse than both control groups when having to perform the tasks from a third versus a first person perspective. Individual analysis further revealed a classical dissociation between most anosognosic patients and control subjects in mental (but not visuospatial) third person perspective taking abilities. Finally, the severity of unawareness in anosognosia patients was correlated to greater impairments in such third person, mental perspective taking abilities (but not visuospatial perspective taking). In voxel-based lesion mapping we also identified the lesion sites linked with such deficits, including some brain areas previously associated with inhibition, perspective taking and mentalizing, such as the inferior and middle frontal gyri, as well as the supramarginal and superior temporal gyri. These results suggest that neurocognitive deficits in mental perspective taking may contribute to anosognosia and provide novel insights regarding the relation between self-awareness and social cognition.