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The Neurobiology of the Aware Ego
-Redefining the Self-
by
John H. Dougherty Jr., M.D.
LeAnne I. Dougherty, D.S.W.
Mateja de Leonni Stanonik, Ph.D.
Charles Licata, M.A.
Summary
The traditional ego has been redefined. A new conceptual theory
developed by Hal and Sidra Stone suggests that instead of the
traditional Freudian ego of self- psychology, humans may utilize
an “aware ego”, or executive choice maker. Modern
neuroscience suggests that as we move our center of operation
and “choice making” to the aware ego, we make increasing
use of the anterior cingulate cortex. Recent studies in our laboratory
utilizing PET brain imaging suggest that patients with Alzheimer’s
disease and anosognosia (lack of self awareness) also have a defect
of the anterior cingulate cortex. Through such research efforts,
modern neuroscience is beginning to contribute to the understanding
of the basic physiologic principles of the self.
Aware Ego, Executive Choice Maker, Anterior Cingulate Cortex,
Alzheimer’s disease, PET Brain Imaging.
Advances in modern neuroscience
are making it possible to investigate the neurological and anatomical
substrate of traditional psychological concepts. PET scans (positron
emission tomography), for example, are being used to visualize
(in vivo) the metabolic substrate of executive attention (located
within the anterior cingulate cortex) as well as other attentional
and psychological states.
There has, also, been a progressive and dramatic evolution of
long-held psychological principles. For example, many authors
have redefined the traditional Freudian concept of ego. A new
conceptual theory developed by Hal and Sidra Stone Ph.D. has made
a major contribution to the development of this redefined ego
(Stone & Stone, 1993). The Stones suggest that instead of
the traditional Freudian concepts of superego/id and its controlling
ego of self-psychology, humans operate with multiple subpersonalities
or selves. These subpersonalities are divided into primary selves
who control our world and with whom we identify. The primary selves
are frequently developed to protect the vulnerable child. These
selves may be conscious or unconscious. According to the Stones,
the traditional Freudian concepts of ego is represented by the
multiple primary selves, with which we are identified. Because
of this identification with the constellation of primary selves
the traditional ego does not have access to an active choice maker.
Examples of primary selves often include the rational mind, pleaser,
and inner critic. In contrast the disowned selves are subpersonalities,
which we repress and condemn, or project onto others. Examples
might include the emotional self, the rebel, vulnerable child,
and the shamed child. For every primary self there is an opposite
disowned self or selves. Examples of these opposites might include
the rational mind and the emotional self or the pleaser and the
rebel.
Psychology of the Selves and the Aware
Ego.
The Stones, however, postulate
the existence of an Aware Ego. The Aware Ego is an active choice
maker, which experiences the primary and disowned selves and is
capable of viewing the process from a position of awareness. The
Aware Ego is not identified with the primary selves. The Aware
Ego has access to both the emotional and higher cognitive "energies".
The Aware Ego has awareness of the experiences of the selves (primary
and disowned) and often stands between these opposites. These
selves may, in fact, represent an “energetic gift”
to be used by the Aware Ego. The Aware Ego is an executive choice
maker and does not judge the primary or disowned selves. With
facilitation (through a process called voice dialogue), the “Aware
Ego Process" can result in a strengthening of awareness and
a progressive separation from ones identification with the selves.
Recent neuropsychological studies have done much to elucidate
the anatomical and physiologic substrate of this executive choice
maker. Neuroimaging studies by Posner and Raichle have demonstrated
that executive attention (selective attention) is mediated in
the anterior cingulate cortex (Posner & Raichle, 1998). They
have found that the anterior cingulate cortex has complex and
rich inputs from both the emotional brain and higher cortical
centers. They demonstrated that the Stroop test clearly and reliably
activates the anterior cingulate cortex. The Stroop test requires
that one make careful discernment when one is confronted with
incompatible or incongruent color stimuli.
Selective Attention – Higher
Control Areas and Emotion.
In addition, Heilman (1997)
in his review of the anterior cingulate cortex points out that
conflict monitoring, response selection and initiation of action
are all critical components of the function of the anterior cingulate
cortex. Profound apathy and even akinetic mutism may represent
severe clinical pathological states involving the anterior cingulate
cortex. He also suggested that the anterior cingulate cortex (ACC)
represents a convergence zone for the limbic emotional brain and
other higher cortical (more rational) structural areas. According
to Hielman, there are rich inputs into the ACC from the hippocampus
(non emotional memory) the amygdala (emotional memory) the periaqueductal
gray (primitive emotion) as well as higher cortical areas.
Allman and associates (2002) suggest that the ACC appears to be
a specialization of neocortex rather than a more primitive stage
of cortical evolution. They stress that the ACC may be central
to intelligent behavior and is closely associated with emotional
self-control, focused problem solving, error recognition, and
adaptive responses to changing conditions. They have identified
a unique class of spindle shaped neurons in the anterior cingulate
cortex that appear to be found only in humans and the great apes.
They suggest that these cells may represent a recent evolutionary
specialization and that they emerge postnatal (after birth). They
speculate that these cells may be important in adult competence
and may be critical for emotional self-control and problem solving
capacity.
Spindle Cells (Human ACC).
In our laboratory, we have attempted
to further elucidate the nature of the anterior cingulate cortex
by studying patients with Alzheimer's disease and anosognosia
(Michon, Deweer, Pillon, Agid & Dubois, 1994). Anosognosia
is defined as the inability to recognize the state of illness
in one's own organism. Patients with Alzheimer's disease and anosognosia
lack the ability to identify their own, often profound, memory
or other cognitive deficits. Anosognosia appears to be present
in approximately 40% patients with Alzheimer's disease.
The mechanism of anosognosia for cognitive deficits remains unknown.
Early studies on Alzheimer's disease (AD) focused on denial as
being the primary cause of a patient’s lack of insight.
One of the earliest empirical studies investigating AD and anosognosia
was performed by Reisberg and colleagues (1985). The study reported
significantly less awareness of cognitive deficits in moderate
to severe AD cases when compared to mild cases. The researchers
proposed that anosognosia might be a result of a defense mechanism
that attempts to protect the individual from knowledge of their
illness and thereby avoiding possible depression.
To explore this idea, there have been numerous attempts to examine
the correlation between severity of Alzheimer's disease and depression.
Feher (1991) reported a weak correlation between anosognosia and
depression, while in contrast Sevush and Leve (1993) reported
a significant correlation. A study by Reed and associates (1993),
however, found no significant correlation between depression and
anosognosia in Alzheimer's disease patients.
Recent studies have shown that Alzheimer's patients with anosognosia
have significantly more severe deficits on frontal lobe related
neuropsychological tests (Heilman, Barret & Adair, 1998; Heilman,
1997). This research supports the idea that the appearance of
anosognosia within AD may have an underlying biological construct.
Furthermore, it suggests that anosognosia may have special relevance
to phenomenal consciousness because it may represent a clinical
pathologic state in which there is a fundamental alteration or
distortion of the personal self.
Because of the conflicting results in past anosognosia research,
we developed a new anosognosia instrument (Cole Anosognosia Scale
for Alzheimer’s disease or CAS-AD) (Licata, de Leonni-Stanonik
& Doughterty, 2002). The primary difference in our instrument
is the use of questions, which pertain specifically to frequently
observed Alzheimer's symptoms. The CAS-AD is composed of 43 questions
relating to 3 different cognitive domains: executive functioning,
memory, and behavior. The instrument was designed to measure a
patient’s lack of awareness on a continuum that allowed
us to identify individuals who were suffering from pronounced
anosognosia.
Results of anosognosia PET study.
To investigate the biological
and structural nature of anosognosia we performed PET scans (positron
emission tomography) measuring focal brain metabolic activity
in Alzheimer's patients with and without pronounced anosognosia
as measured by the CAS-AD (Dougherty, de Leonni-Stanonik &
Licata, 2001). The study used 18FDG as a metabolic tracer to identify
areas of increased or decreased glucose utilization in the brain.
Of specific interest to us was the nature of selective attention
(executive attention) and its relationship to anosognosia. A variation
of the Stroop test, called the Counting Stroop, was used in order
to produce metabolic activation in the ACC. Our study suggests
that patients with Alzheimer's disease and pronounced anosognosia
have an abnormal decrease in glucose utilization within the anterior
cingulate cortex when compared to patients without anosognosia.
We conclude that anosognosia in Alzheimer's disease may represent
a deficit in the ability of focusing selective attention on one's
self and this may result in a functional abnormality in the Aware
Ego.
These studies suggest that the executive choice maker (aware ego)
appears to be associated specifically with the anterior cingulate
cortex and may represent a unique human capacity for informed
decision making. In addition, borderline personality disorder
and other psychological states have recently been associated with
pathology of the anterior cingulate cortex (Posner and assoc,
2002). Is it possible that the "aware ego process" results
in increased numbers or increased connectivity of spindle cells
in the anterior cingulate cortex?
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Biography
John H. Dougherty Jr.,
MD
University of Tennessee Medical Center, Knoxville, Tennessee
Assistant Professor of Medicine (Neurology)
Director of Cole Neuroscience Center, Knoxville, Tennessee
Memory Disorder Clinic
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