DISORDERS OF ATTENTION

Ruhi Pai
M.Phil 1st SEMESTER
 ATTENTION
• The term Attention was given by William James in
1890.
• “It [attention] is the taking possession by the mind, in
clear and vivid form, of one out of what seem several
simultaneously possible objects or trains of thought.
Focalization, concentration, of consciousness are of
its essence. It implies withdrawal from some things
in order to deal effectively with others, and is a
condition which has a real opposite in the confused,
dazed, scatterbrained state.”
 TYPES
• FOCUSED- focus on one stimuli while suppressing
others. (dealing with distractions)
• SUSTAINED/ VIGILANCE- maintaining of attention.
(through vigilance test)
• DIVIDED ATTENTION- allows us to get involved with
multiple elements. Alternative attention allows us to
shift focus of attention.
• INVOLUNTARY- reflective/ exogenous
• VOLUNTARY- goal driven (intentional).
• OVERT vs COVERT
 Alteration in degrees of attention
• Attention is a limited capacity. States like fatigue , depression,
boredom directly influence it.
• Drug – alcohol induced states, epilepsy, intracranial pressure
build up. All what influences consciousness will hamper
attention.
• Lack of attention and concentration denotes an inability to
focus on an object in a purposeful way- indicating weakening
of determining tendency. (in case of mania or hypomania-
attention weakening and distractibility increasing).
• In case of schizophrenia attention takes a more involuntary
form towards hallucinations, delusions or strong emotions
felt.
 PSYCHOSIS AND ATTENTION
• Alteration in external perception is associated with
change in attention
• Functional hallucinations- associated with normal
perception, seems to be in the background and not
the focus of attention.
• Visual-Pseudo hallucinations- removed by just
looking at it.
• Pareidolic illusion- more prominent with increased
attention- making sense of Rorschach cards- seeing
faces in it.
 NUEROPHYSIOLOGY
• Ascending reticular activating system (ARAS).
The other components of this system of a
series of brainstem (substantia nigra, ventral
tegmental area, raphe nuclei, and locus
coeruleus) and basal forebrain nuclei. Activity
in the ARAS results in a wakeful state. Changes
in the state of arousal will thus clearly
influence cortical and subcortical areas
involved with attention.
 Other regions
• Superior Corriculus- supra nuclear palsy
• Pulvinar region of the thalamus- filtering
process- responds to color, orientation,
motion.
• Cingulate Gyrus – emotional tone- stroop
• Parietal lobe- Hemineglect
• Frontal lobe- important for orienting eye gaze
and attention.
 DISORDERS OF ATTENTION
• The main attentional disorders are confusional
states, partial (domain-specific) attentional
syndromes, and hemispatial neglect, balint’s
disorder.
 Confusional states

• A confusional state (or delirium) is a global change in mental

status wherein the principal cognitive deficit is a change in
the overall attention tone. It is the most common
disturbance of mental status seen by physicians. Associated
symptoms can include incoherent thinking, distractibility,
perceptual disturbances including illusions or hallucinations,
disco-ordination, delusions, impaired judgment, reduced
insight and agitation. Some of these disturbances may arise
because of the attentional disorder while others may arise
separately.
• Associated cognitive deficits such as an anomia, dysgraphia,
dyscalculia, or constructional difficulties.
 ATTENTION DEFECIT DISORDER

Inattention means a person wanders off task, lacks persistence, has

difficulty sustaining focus, and is disorganized; and these problems are
not due to defiance or lack of comprehension.
Hyperactivity means a person seems to move about constantly,
including in situations in which it is not appropriate; or excessively
fidgets, taps, or talks. In adults, it may be extreme restlessness or
wearing others out with constant activity.
Impulsivity means a person makes hasty actions that occur in the
moment without first thinking about them and that may have high
potential for harm; or a desire for immediate rewards or inability to
delay gratification. An impulsive person may be socially intrusive and
excessively interrupt others or make important decisions without
considering the long-term consequences.
 Partial attentional syndromes

• Attentional impairments can also present

more focally as domain-specific or ‘partial’
attentional syndromes
• changes in visual-based attention could result
in reduced detection of stimuli in the
environment, while changes in language-
based attention could present as reduced
verbal fluency.- Careful not to diagnose it as
aphasia.
 Hemispatial neglect

• This disorder, one of the most clinically dramatic in

neurology, is characterized by the inability of the patient
to orient towards, respond to, or report on, stimuli on
the contralesional side of space. Neglect is a multimodal
deficit and may affect any or all sensory modalities,
motor behaviours or even the internal representations of
memories and other thoughts. Most often, the left
hemispace is neglected, as the disorder is more frequent
and severe following right hemisphere injury.
• For eg if they are grooming , the may ignore a particular
side of their face.
 Phenomenon of extinction
• Eg, lesion on the right side. Patient shown a flash of light to
the left can still detect the flash of flight now presenting two
stimulus simultaneously makes the detection in the
contralesional side difficult to perceive. Competing stimulus –
contralesional stimulus difficult to perceive
• com
 Balint’s syndrome

• Balint’s syndrome
• This is a rare but very disabling condition in which the
individual manifests as a cluster of symptoms that could easily
be mistaken for blindness for all but a very restricted area of
the visual field. However, such individuals are not blind, and
can actually ‘see’ objects anywhere in the visual field if they
can direct attention to that location – and herein lies the
problem.
• Balint’s cases cannot point
• Balint’s is almost always associated with bi-lateral damage to
the occipital-parietal borders, and is also known as dorsal
simultanagnosia.
• Balint’s syndrome and hemineglect demonstrate that our
ability to construct a complete model of our visual world
depends on being able to attend to different elements of it, to
switch attention to new objects or new regions of space very
quickly, and to use this specific information to build a
relational map of the ‘big picture’.
• In uni-lateral neglect, parietal damage means that this skill is
lost (usually) for the contralateral visual field. As a result,
attention appears to be focused on the remaining intact half.
The person is not blind to the other half of the visual field,
and can, under certain circumstances, see objects in it. But
ordinarily, their attention is restricted to one half of the visual
field
Balints
 DIFFERENCE
• Neglect is the result of unilateral lesions of the
parietal, posterior temporal, and frontal
cortex. Neglect also can be due to damage in
subcortical areas including the basal ganglia,
thalamus, and midbrain. Bálint’s patients
suffer from bilateral occipitoparietal lesions.
 SCALES OF ATTENTION
• MARS RATING SCALE BY WHYTE AT MOSS TBI model
system at MOSS rehab.
• 22-item MARS. Each item is a behavioral descriptor
rated on a five-point Likert-type scale according to
how well that behavior describes the patient, ranging
from “definitely true” to “definitely false.” Items are
phrased so that the rater considers behaviors
indicative of both good and impaired attention.
• Factors underlying mars- Restlessness/ Distractibility,
Initiation, and Sustained/ Consistent Attention.
 Scales ..
• Conner’s Rating scale for ADHD
• Digit span test of attention – for delirium and
dementia
 TESTS OF ATTENTION
• ACT – Attentional Capacity test
• Evaluates child’s selective attention
• Designed for motor / speech impairment children.

• CPTS- Continuous Performance Tests.

• Computer based.
• Evaluates attention (sustained attention).

• CPT II – Connors CPT II Continuous Performance test II

• 14 minute computer test.
• Subject has to press the space bar immediately after seeing stimulus on the screen.

• Connors Kiddie CPT V.5

• 4-5 years of age.
• Quick flashes of similar objects .
• This test is like CPT II buts its used for a younger group and it uses pictures instead of
letters.

• IINTERGRATED VISUAL AND AUDITORY CONTINUOUS PERFORMANCE TEST (IVA)

• Uses visual images and sounds to access all domains of ADHD.
• 5 years plus.
• Clients need to click the mouse on hearing a particular sound “ like one” and not 2.
 SOURCES
• Gitelman,D.R.(2003). Attention and its disorders:
Imaging in clinical neuroscience. British Medical
Bulletin, Volume 65, Issue 1, Pages 21–34,https://
doi.org/10.1093/bmb/65.1.21.
• Stirling, J.(2008) Introducing nueropsychology .
• Gazzaniga,M.S.,Ivry,B.R.,& Magnun,G.(2014).
Cognitive Nueroscience. 4th edition. Pg 272-280