A Neurology of Awareness and Belief: So near So Far?

Cognitive neuroscientists have used cognitive frameworks to interpret the various forms of breakdown in the “belief” system (e.g., misidentification, anosognosia, confabulation, asomatognosia, somatoparaphrenia, etc.) observed following focal (right) brain damage. Some cognitive theories can account for the formation of false beliefs but not for bizarre and persistent delusional states resistant to challenge. In his Target Article, Todd Feinberg has integrated psychoanalytic theory, detailed case study, and neuroscientific research knowledge to offer a synthetic account of these positive symptoms. Although they may appear superficially different, in his view in all of these disorders it is possible to detect abnormalities in some aspect of self-awareness and signs of regression to immature styles of thinking and ego functioning (e.g., denial, projection, splitting, and fantasy). One limitation of this argument is that apparently similar forms of brain damage and dysfunction do not always cause the same or even any abnormalities of belief and awareness. A way of confronting this objection, which Feinberg does not explore, is to use some variety of the cerebral reserve concept but specifically applied to cognitive reserve for the self-related functions as an individual diathesis to disorders of belief that makes the emergence of these symptoms more likely.