Left side neglect after a stroke

by Fiona Rae / 05 December, 2011
Strokes or brain injuries can cause hemineglect, in which the brain sees only half the world.

Grainger Hall was a fit 70-year-old working in encryption for a major bank when, four years ago, he had a stroke. It was serious enough that at one stage it looked as if he and his family would be saying their farewells. But these days he is perfectly mobile, his speech is fine and anyone who met him wouldn’t guess what he’s been through.

To his family he’s the same but also different – one of the consequences of the stroke is he now often fails to notice what’s happening on the left side of his world. This became apparent in the days and weeks after the stroke, as Hall began to recognise his family again and recover his movement and speech – he shaved only the right side of his face, ate what was on the right side of his plate and didn’t notice the grandchild standing in front of his left knee. In those early weeks, according to his wife, Lynne, he wasn’t always aware he had a left arm.

Hall has what is called hemineglect – in his case left-side neglect – a condition in which the brain seems to divide the world in two and then ignore one of the halves. It is probably more common among those who have suffered a stroke than is generally recognised. In most cases it goes away after a few weeks, but in others becomes a permanent state of being. For Hall, the condition is far less apparent than it once was, although Lynne says her husband still often fails to notice anyone on his left side. “It’s a fascinating condition,” says his daughter, Vicki. “I just wish it wasn’t Dad who had it.”

Hemineglect is generally the result of damage to the parietal lobe in the right side of the brain, which attends to the left side of space. For some reason, damage to the left side of the brain rarely results in people neglecting the right side of space. Professor Michael Corballis, in his recent book Pieces of Mind, suggests this has to do with the asymmetry of the human brain. “One argument is that language has taken over the left side of the brain and made it deficient in spatial terms,” he says. “Damage to the left side impacts on language, but when there is damage to the right side, the language is fine but you lose attention to space.”

Hall puts things down to a loss of peripheral vision, also a consequence of his stroke, yet hemineglect is not about being unable to see the left side of the world, but about refusing – or being unable – to pay any attention to it. “I think there is a little bit of denial there, darling,” Lynne tells her husband, when he refers to his poor vision in the lower left quartile. “Often you’re not aware of us … it will be quite a few seconds before you’ll see people if they’re on your left.”

“That’ll be because he’ll be out of my range of vision,” says Grainger.
“No, it isn’t,” says Lynne.
“Or it’s probably because I’m concentrating on something else.”
“No, it isn’t.”

A common characteristic among people with hemineglect is that they don’t believe they have the condition, and will find alternative explanations for anything that suggests they do. Psychologists, neuro­psychologists and neuroscientists call it “denial”, but it is not denial in the usual sense. People aren’t deliberately pretending that things are other than they are. Yet the excuses can be very creative.

Jenni Ogden studied more than 100 people with hemineglect for her PhD 30 years ago, and has written about the condition in her upcoming book, Trouble in Mind (to be published in February). Ogden remembers asking one of her case studies, a woman called Janet who had extreme hemineglect, to copy a simple line drawing of a scene consisting of, from right to left, a tree, a house, a fence and another tree.

Janet drew the tree on the far right and most of the house. When Ogden asked her if she would draw the fence, Janet’s response was: “Well, I will if you really want me to, but it will probably blow down in the next wind.” And when she asked Janet to draw the other tree, Janet told her she couldn’t draw trees.

It may be frustrating for those living with people with hemineglect, but for the person with the condition, denial could be a sound adaptive response to a world that has shifted. “Perhaps when patients find themselves bereft of some ability that they have previously taken for granted, and can’t understand it, they might need to rationalise it for their own peace of mind,” says Ogden.

Hemineglect can manifest in all sorts of ways. In more extreme cases, people won’t acknowledge one half of their body, and even disown their own limbs. It can involve the neglect of different stimuli – visual, auditory or sensory. It may be environmental or object-related. When Ogden asked some of her subjects to copy a picture, she found some would draw half the entire scene, and others would draw half of the different objects within the scene.

The condition not only pertains to the real world, she notes, but the imagined one. In one famous experiment, an Italian researcher got people to recall a scene they were familiar with, by asking them to imagine they were standing outside a cathedral and to describe the buildings they could see. They were then asked to do the same while imagining they were facing the cathedral. In both instances, they recalled only the buildings that, in their real world, would have been on their right side.

Yet people with hemineglect may sometimes pay attention to the left side of things when they are motivated to do so. For instance, Lynne Hall got a kitten – which she called Amy Winehouse – “because I knew that Grainger would never want to step on a kitten”, she says, laughing. And true, he never has. “So Amy Winehouse has been a great success. It got him to turn to the left.”

Ogden once asked people to pick up the tokens in front of them, according to the different shape and colour of the tokens. Most of her subjects picked up only the tokens from the right side. Then she replaced the tokens with coins of different denominations, telling her subjects they could keep what they collected. “And some of them, not all of them, who didn’t pick up the tokens on the left, would pick up the coins [on the left].”

But Ogden notes that although people can sometimes be encouraged to pay attention to the left side of their world, any success usually pertains only to a specific context and for a period of time. And despite the condition having attracted considerable research in the past two decades, nobody has yet developed an effective rehabilitation strategy – it doesn’t help that people who have hemineglect don’t believe anything’s wrong.

“You can do all sorts of fancy things to put them through trials, but then you think why do it? There comes a time when you think do whatever you need to do to make the best sense in your world.” This is also reflected in Lynne Hall’s response when asked if she had any advice for those living with hemineglect – or perhaps, more pertinently, people living with people with hemineglect. “Patience, more patience and tolerance. You just play it by ear really.”
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