Tag Archives: behavior

Anosognosia, Psychopathy, and the Conscience

How people see and understand themselves is likely to have an impact on how they interpret interactions with others. Here, I briefly explore the brain areas implicated in anosognosia, how these areas are also relevant in psychopathy, and why anosognosia is important when considering the crime and the conscience.


Anosognosia is defined as the impaired ability of patients with neurological disorders to recognize the presence or adequately appreciate the severity of their deficits [1]. Torrey (2012) cites three examples of anosognosic patients; a stroke victim with a paralyzed arm claimed he couldn’t lift it because he had a shirt on; a woman with paralysis in her left arm was asked to raise it, and instead raised her left leg. When this was pointed out to her she responded that some people call it an arm, others a leg, and jokingly inquired as to the difference; the Supreme Court Justice, William Douglas, was paralyzed on his left side. He claimed this was a myth, and was still inviting people to go hiking [2].


Recent research on this phenomenon has identified deficits in the brain of the patients who in all honesty do not recognize that they are in some way impaired. By using fluorodeoxyglucose positron emission tomography (FDG-PET) and single photon emission computed Tomography (SPECT) Perrotin et al. (2015) found that anosognosic Alzheimer’s patients had a disruption in connectivity between the posterior cingulate cortex (PCC) and the orbitofrontal cortex (OFC) [1]. Ries et al. (2007) also implicated a compromised precuneus in anosognosic patients. These midline structures are susceptible to damage in those with Alzheimer’s Disease (AD) and stroke victims. Anosognosia is also experienced by schizophrenic patients; according to Gerretsen et al. (2015), 60% of schizophrenic patients experience moderate to severe illness awareness, and this can lead to medication non-adherence and poor treatment outcomes [4]; they found left hemispheric dominance in the left prefrontal cortex in anosognosic schizophrenic patients and cortical thinning in the temporoparietalocciptal junction (TPO).

There is still much work to be done to determine the mechanistic and functional basis of anosognosia, and to determine the subtleties between illnesses and disorders, but research is starting to identify suspect brain regions. This is useful if anosognosia is questioned in other disorders, because neurological studies exploring the disorder can be explored and legitimate avenues of scientific inquiry explored.


A failure to recognize a disorder is also present in those with psychopathy. While anosognosia is yet to be explored thoroughly in those with psychopathy, there are behavioral items on the Psychopathy Checklist (PCL-R) [5] that suggest anosognosia is present; grandiose sense of self-worth, lack of remorse, and failure to accept responsibility. The sense of self-worth and narcissistic traits of the psychopath clearly means that they think very highly of themselves. This negates the idea that the psychopath believes they suffer from a defect or a disorder; at the most they might recognize that most others are different, and perhaps inferior to themselves. If a lack of remorse is experienced, this is an explicit demonstration that they do recognize, at least on an emotional level, the consequences of their bad behavior as being wrong; if they do not believe their behavior is inappropriate, it stands to reason that they believe they behaved appropriately, and thus experience nothing ‘wrong’ about themselves. This aspect of self-belief and self-reflection is also seen in the psychopath’s failure to accept responsibility; if they are always good and right, there is little motivation to make amends.

Based upon this cursory examination of psychopathic behavior, it would seem reasonable to explore the neurological studies of psychopathy and see if there could be some overlap with previous studies on anosognosia, and in fact some of the same compromised brain areas are implicated. Many studies have demonstrated developmental differences in the PFC of the psychopath (for a review, see Umbach et al. (2015) [6]), and the white matter pathways, such as the uncinate fasciculus (UF) connecting to the PFC from the limbic regions [7]. Perrotin et al. [1] hypothesized that Anosognosia can result from a disruption in connectivity in the UF. When exploring connectivity in the frontoparietal network (FPN), Philippi et al. (2015) found reduced connectivity in those with higher scores on the PCL-R, which included the right precuneus. And to further the overlap, Glenn et al. (2009) [8] found that those with who scored high on the interpersonal factors of the PCL-R (manipulative, conning, deceitful), showed reduced activity in the PCC during an fMRI scan when having to make judgments during moral dilemma scenarios.

Anosognosia and psychopathy both demonstrate complex neurological constructs, and it is premature to conclude that the neurological basis for Anosognosia (itself still understood) would tuck neatly into the already known neurological research on the psychopath. However, given the neat juxtaposition of behavioral traits and neurological dysfunction, it is worth bringing psychopathy into discussions of Anosognosia for the following reason. The research on psychopathy is currently deeper and richer than the research on anosognosia, and behavior of the psychopath has been widely observed and studied. If we can reasonably conclude that psychopaths, particularly criminal psychopaths, are also anosognosics, their behavior can be assessed in light of what it means to recognize no disorder or defect within oneself. The parallel is further relevant with psychopathy when considering that a number of those with schizophrenia, and a minority of those with AD, have been known for antisocial, and sometimes criminal, behavior [9, 10].


Those with schizophrenia and AD also suffer from abuse, but when they have been known to act violently, their behavior and motivations need to be understood. Torrey (2012) has documented extensively the violent acts of those with schizophrenia [2]. There is usually a history of progressively worse episodes of psychosis that can convince the patient that they are receiving supernatural or alien instructions to kill or harm individuals, and more often than not family members. Whether or not the auditory hallucinations slowly convince the patient over time of the necessity for deadly action, or whether the act is impulsive, after the event the patient often remains remorseless and attributes their behavior to necessary and mandated (often divine) reasons. This state of mind is similar to the violent psychopath, who also viewed his violent actions as necessary and fully justified. The problem is never attributed to the self; a disorder or defect is not recognized. While psychopaths are widely regarded as not having a conscience and experience only limited affect, more research is needed on the experience of conscience by schizophrenics, especially understanding the role that psychosis played in circumventing the conscience and providing them with permission to act. It is also crucial to discover how those events are remembered and felt post psychosis, perhaps when the patient has reconvened their medication.

In illnesses and disorders that can be associated with antisocial behavior or aggression, anosognosia could be a partial reason for the event of the behavior. Not recognizing any problems or defects, and thinking that one acted rightly or righteously, will affect personal judgments on the self-evaluation of behavior. This does not provide a fertile ground for remorse or responsibility, and if the behavior was aggressive, the patient could continue to remain dangerous, inflexible to a reasoned and peaceful behavioral change. This makes the search for the neural representation of anosognosia all the more crucial, treatment all the more pressing, and methods of identification all the more necessary.

© Jack Pemment, 2016



  1. Perrotin, A. et al. (2015). Anosognosia in Alzheimer disease: Disconnection between memory and self‐related brain networks. Annals of neurology, 78(3), 477-486
  2. Torrey, E. F. (2012) The Insanity Offense, New York, W. W. Norton and Company
  3. Ries, M. L. et al. (2007). Anosognosia in mild cognitive impairment: relationship to activation of cortical midline structures involved in self-appraisal. Journal of the International Neuropsychological Society, 13(03), 450-461
  4. Gerretsen, P. et al. (2015). Illness denial in schizophrenia spectrum disorders. Human brain mapping, 36(1), 213-225
  5. Hare, R. D. et al. (1990). The revised Psychopathy Checklist: Reliability and factor structure. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2(3), 338-341
  6. Umbach, R. et al. (2015). Brain imaging research on psychopathy: Implications for punishment, prediction, and treatment in youth and adults. Journal of criminal justice, 43(4), 295-306
  7. Motzkin, J. C. et al. (2011). Reduced prefrontal connectivity in psychopathy. The Journal of Neuroscience, 31(48), 17348-17357
  8. Glenn, A. L. et al. (2009) The Neural Correlates of Moral Decision-Making in Psychopathy. Retrieved from http://repository.upenn.edu/neuroethics_pubs/55
  9. Fazel, S. et al. (2009). Schizophrenia and violence: systematic review and meta-analysis. PLoS Med, 6(8), e1000120
  10. Lopez, O. L. et al. (2003). Psychiatric symptoms vary with the severity of dementia in probable Alzheimer’s disease. The Journal of neuropsychiatry and clinical neurosciences, 15, 346–353

A thought on behavior and language

I’m finding it quite paradoxical this morning that the word ‘behavior’ is a noun and not a verb. Behavior is indicative of doing things, and verbs are ‘doing’ words. There’s the verb ‘to behave,’ which is to act within the parameters of social or familial expectations, but there’s no I behavior, you behavior, he/she/it behaviors…

I’m quite convinced that I am behavioring all the time.

Ideology: Behavior protocol or excuse?

I am continually interested in how our beliefs shape our behavior, if indeed they do. This notion is especially important when considering extreme behaviors such as murder and pedophilia. While it is not uncommon to discover that mass murderers seem to have been “wrapped up” in some kind of sub-culture morality or extreme political/religious ideology, we also have to bear in mind that justifications for behavior come both before and after an act. If it comes before an act, was it ideology based (i.e. ideology governed the behavior), and if the justification comes after the act, is it an excuse (i.e. a rationalizing of the act – to oneself or the public)?

In terms of learning and repeating certain kinds of motor behavior, it seems obvious that certain repertoires get set into our brains (the cerebellum plays a key role in this). But how do beliefs manifest themselves as behavior? The obvious thing to do here would be to ask, “Okay, what is a belief?” – I’m going to work with the delightfully vague definition of “something I take to be true.” And what is truth? That’s an easy one. It’s something that provides me with reinforcement.

In an immediate way, we trust our senses and take the subsequent perception to be true because they facilitate our navigation and passage through our environment, providing us with very necessary information – if these senses fail us, then they are not being true (this happens even when there are no deficits/disorders/diseases hindering the transduction of environmental stimuli). But in a conceptual sense, knowing that Charles Dickens wrote Oliver Twist, firstly can be reinforcing because it promotes the positive feeling that I know something, and secondly, knowing this fact can facilitate the accumulation of more knowledge around it; everything we know about Dickens fits together and is facilitated by the fact that Charles Dickens wrote Oliver Twist. Clearly, our senses and our conceptions are not always right, which tells us something very important; learning requires us to shun the potential for reinforcement, and this can be very unsettling.

Ideology, therefore, is the stream of conceptions that has provided us with maximum amounts of reinforcement – more so than any other alternatives. This is clearly why we all have different “truths” about the world. So in terms of our beliefs governing our behavior, we are clearly expecting some kind of reinforcement upon the completion of the act; even suicide and the idea of suicide can seem highly rewarding in terms of how the individual sees their life, or how they would like to be remembered by others. The more planning and thought that goes into these acts, clearly increases the likelihood of the outcome. The more thought, the more anticipation of the reinforcer. The act becomes inevitable, at least for the individual, provided no one intervenes.  This anticipation, probably leads to a behavior protocol.

After the event, however, people still turn to ideology to justify it, and if this is the case, they probably never understood why they did what they did, or they were taking pleasure in toying with the media and the public (such as David Berkowitz telling the press that his neighbor’s dog was telling him to murder), or they felt telling the truth behind their motives would not be met with much sympathy or understanding. In the first instance, confusion, it is not hard to see that we do a lot without thinking – in fact, that’s a good thing because if we had to think through every little thing we do, such as preparing food, walking to and from the store, brushing one’s teeth, or picking up a hot drink, we would never get anything done. But this doesn’t really require ideology as an explanation, unless you want to get metaphysical. This lack of explanation could also apply to serial killers and serial rapists; they do what they do because the only way they get maximum exhilaration is by committing extreme acts and engaging in excessive drug and alcohol intake; ideology as an explanation is not required here. While there is this impulsive behavior, it must also be noted that many attacks are also highly planned, which takes us back to ideology motivating behavior.

It’s easy to see why psychopaths would throw ideology at the media; the public likes a good story and the fact that they are manipulating the public while remaining in the spotlight would no doubt assuage their ego; but as this is contrived nonsense, it is not an explanation of ideology explaining the act in question. Telling the truth about the thoughts and planning that went into a killing, is simply admitting that there was ideology before the killing.

Ideology has to be present before the act for it to be used as an excuse for the behavior. If ideology wasn’t there before the behavior, then you can’t make the behavior fit one. This is important because it tells you that the act was governed by impulses and the reptilian brain, rather than the use of the frontal lobe, which is involved in planning and forecasting. This difference can tell you something about the neurology of the individual, and tell you about the kind of person you are dealing with.

The Pinocchio Effect: Lying does change us

Yang and Raine et al. (2007) of the University of Southern California found that pathological liars have an increased amount of white matter in their ventral and lateral frontal lobes (this can be as much as a 36% increase in the inferior frontal cortex).

Yang and Raine et al. propose that this increase in white matter either predisposes a person towards pathological lying or is the result of the continued behavior of lying, i.e. the more you lie, the greater the amount of white matter generation in your frontal lobes.

The frontal lobe is known for executive functioning such as forecasting and predicting, and is also believed to be the association area for working memory. As lying no doubt involves a lot of frontal activity, it is not surprising that it neurologically adjusts to become better suited to the task. White matter comprises of myelinated axons that allows increased and efficient communication between brain regions. As lying is an activity that involves a lot of creativity, naturally communication between brain regions needs to be running optimally.

Localisation of increased prefrontal white matter in pathological liars

Book Review: The Science of Evil / Zero Degrees of Empathy (Simon Baron-Cohen)

I have just finished reading this fantastic book and already know that I will be consulting it again and again in the future. Baron-Cohen very tactfully explores morality on the personal level and from historical examples of heinous acts, such as the Holocaust. His expertise with those who characteristically have no/little empathy, such as psychopaths, those suffering from borderline personality disorder, narcissists, and those suffering from varying degrees of autism is used to construct two views, zero-negative and zero-positive. Zero-negative represents those with no empathy and their actions can only be detrimental to themselves or/and others, whereas zero-positive represents those with autism, who have a remarkable propensity for memorization and logic.

His ideas about empathy are grounded heavily in the brain, where he discusses the brain regions involved, and how nature and nurture clearly help to shape the brain’s moral capacity. Baron-Cohen challenges his readers to think about “evil” in light of neurological scholarship in the field of empathy, helping us to see empathic actions as part of a bell curve, rather than polarizing actions into good and evil.

Highly recommended.

Knowledge and Addiction

Can knowledge acquisition fall into an addiction model?

The thought of being addicted to knowledge appears somewhat ridiculous, after all, knowledge acquisition is seen as laudable and a necessity for a rich and fulfilling life. Knowledge is if often heralded and even worshipped by cultures the world over; indeed knowledgeable individuals are valued and seem to command a certain level of respect. Knowing more about something than somebody else can even serve to boost one’s social status, and once we realize that we can never know everything, we mandate and support the use of academic professionals for the sake of finding out more truths; truths that we can lap-up, think about and discuss without doing the cognitive fieldwork. So even now we can begin to see the craving and the use and abuse of information. In short, we just cannot do without it.

Finding out something new can often be a thrilling experience, urging you on to build-upon this thrilling piece of new information, or seeking another hit of information to reward you with the same feeling as before. If humans can rapidly learn cues and contexts that predict the availability of addictive drugs (von de Goltz; Kiefer, 2009), what is to say they are not using the same cognitive machinery to learn where to obtain another hit of information? A friend, the Internet, a book, a library, or a professor, and this exchange can often take place quickly and efficiently in the comfort of one’s own home with the use of a phone, a computer or a television. Finding a source of knowledge is in fact rewarding in itself and will quickly become highly valued and used for future acts of knowledge acquisition.

Behavior that constitutes addiction is often known to be both impulsive and compulsive. Impulsivity is marked by rapid and unintended reactions to internal and external stimuli, without regard for negative consequences. Compulsive behavior is characterized by perseveration in the face of adversity (Koob, 2009). It is not hard to see how knowledge acquisition fits both of these behaviors. Reading news headlines, texting and responding to text messages, the sudden urge to see how an entertaining plotline continues at the point of a cliffhanger, the use of social internet sites to view a status update of friends (or enemies), and waiting by a phone in the anticipation of receiving important information all represent an impulsive need to know. And as our attention is directed at receiving this information we can easily become blind to the consequences. This can range from short term foibles like automobile accidents caused by using a phone or an animated conversation with a passenger, to the long term neglect of friends, family and pets if the behavior is not moderated.

Compulsive and impulsive behavior can be seen in the light of delayed reinforcement.  When we act to obtain reinforcement, there is always a delay between the action and the outcome, and thus to control the world successfully, animals must be able to use delayed reinforcement (Cardinal, 2001). How well we control our anxiety caused by the anticipation of knowledge is the difference between compulsive and impulsive behavior; the perceived reward remains the focus, but the time allowed by the individual to achieve their goal differs in accordance with their need. This is perhaps even analogous to the neuronal rewards for sex. Instant gratification by way of masturbation provides a reward for an impulsive appetite, whereas a compulsive appetite is not bound by the need of a quick fix, even though the means of achieving the goal may have developed into an unhealthy obsession. The need to know things instantly can invoke impulsive behavior, but by contrast scholastic behavior is rife with trials and tribulations, yet the anticipatory rewards contribute to the ongoing drive for worthwhile knowledge. Many scholars fight adversity every day for publication in prestigious journals and for validation among their peers, and the best way to do this is to present a new piece of knowledge or an original perspective on an existing idea and hope that it too hijacks the reward system of the right people and satisfies their need for knowledge gratification, or at least the needs of a potential market. Despite this immense adversity, tremendous efforts are made, regardless.

There is perhaps also a difference in the quality of this gratification. Information obtained by the need of a quick fix does not require much thought, whereas those who seek to satisfy their intellect’s engage in long bouts of sustained sensory stimulation to build up their cognitive machinery to better understand the world; the satisfaction gained from this is arguably a greater reward, such as an emotional “Eureka!” moment of discovery.

Dopamine could play a role in the addiction to learning. The mesolimbic pathway delivers dopamine into the frontal cortex, the area of the brain responsible for executive functions, such as planning, forecasting and working memory. Dopamine appears to play an integral role in cognition. Stimulation of the D1 receptor in the PFC is linked to increases in the amount of NMDA receptors and could possibly play a role in NMDA receptor processes in the PFC (Wolf ; Gao, 2008). Increased activity of NMDA receptors can in turn increase AMPA receptors, resulting in long term potentiation and the strengthening of the prefrontal synapse, something that could be vital for maintaining working memory and our natural capacities for problem solving and critical thinking. The study by Wolf et al. goes on to suggest that addictive drugs like cocaine, which block the re-uptake of dopamine, could enhance NMDA receptor activity, which could in turn facilitate the neuronal plasticity that focuses behaviors towards drug-seeking. If natural levels of dopamine are high or dopamine re-uptake is naturally low or inhibited, surely neuronal plasticity could focus on behaviors that utilize the prefrontal neurons, such as working memory and learning, albeit weaker than cocaine addiction? This could present a natural addiction to learning behavior, although there is no evidence to support this claim.

High concentrations of dopamine have been linked to increased levels of endorphins (an endogenous morphine-liked compound) in the mammalian brain (Neri et al., 2008). In rats, β-endorphin has been linked to memory consolidation and memory retrieval (Barros, 2003). Endorphins are well known for the feelings of euphoria produced when they bind to opioid receptors in the brain, and so if increases of dopamine result in increases of endorphins, there could easily be a desire for the organism to replicate the behavior that caused the good feelings. If high levels of dopamine are involved in strengthening synaptic connections in the prefrontal cortex that are involved in cognition, and also producing higher levels of β-endorphin, which aids memory retrieval and memory consolidation, plus creating a mild euphoric feeling, it is not hard to see how the machinery involved in knowledge acquisition is tempting you to repeat this behavior.

I would like to suggest that the reward for learning has to be more than adaptive behavior that could promote the success of the organism. A neuronal reward system would encourage humans to learn and seek knowledge, which in turn would result in adaptive behavior, allowing for the successful cognitive evolution of the species. A biological system of addiction is perfect, as it gives the human a big push towards self-perpetuating beneficial learning behavior, even if misery and negative consequences are experienced along the way.