The perceptual world is organized hierarchically: the forest consists of trees, which in turn have leaves. Visual attention can emphasize the overall picture (global form) or the focal details of a scene (local components). Neuropsychological studies have indicated that the left hemisphere is biased towards local and the right towards global processing. The underlying attentional and perceptual mechanisms are maximally impaired by unilateral lesions to the temporal and parietal cortex. We measured brain activity of normal subjects during two experiments using 'hierarchically' organized figures. In a directed attention task, early visual processing (prestriate) areas were activated: attention to the global aspect of the figures activated the right lingual gyrus whereas locally directed attention activated the left inferior occipital cortex. In a subsequent divided attention task, the number of target switches from local to global (and vice versa) covaried with temporal-parietal activation. The findings provide direct evidence for hemispheric specialization in global and local perception; furthermore, they indicate that temporal-parietal areas exert attentional control over the neural transformations occurring in prestriate cortex.

The study describes the Cardiff Anomalous Perceptions Scale (CAPS), a new validated measure of perceptual anomalies. The 32-item CAPS measure is a reliable, self-report scale, which uses neutral language, demonstrates high content validity, and includes subscales that measure distress, intrusiveness, and frequency of anomalous experience. The CAPS was completed by a general population sample of 336 participants and 20 psychotic inpatients. Approximately 11% of the general population sample scored above the mean of the psychotic patient sample, although, as a group, psychotic inpatients scored significantly more than the general population on all CAPS subscales. A principal components analysis of the general population data revealed 3 components: "clinical psychosis" (largely Schneiderian first-rank symptoms), "temporal lobe disturbance" (largely related to temporal lobe epilepsy and related seizure-like disturbances) and "chemosensation" (largely olfactory and gustatory experiences), suggesting that there are multiple contributory factors underlying anomalous perceptual experience and the "psychosis continuum."

Recent work on human attention and representational systems has benefited from a growing interplay between research on normal attention and neuropsychological disorders such as visual neglect. Research over the past 30 years has convincingly shown that, far from being a unitary condition, neglect is a protean disorder whose symptoms can selectively affect different sensory modalities, cognitive processes, spatial domains and coordinate systems. These clinical findings, together with those of functional neuroimaging, have increased knowledge about the anatomical and functional architecture of normal subsystems involved in spatial cognition. We provide a selective overview of how recent investigations of visual neglect are beginning to elucidate the underlying structure of spatial processes and mental representations.Once considered a unitary syndrome, it is now accepted that visuospatial neglect results from the interplay of damage to several different cognitive processes [1,2]. Even within such relatively simple tasks as copying or spontaneous drawing, patients show many qualitatively distinct patterns of omission and distortion in 'left' space [3].Deficits of attention, intention, global-local processing, spatial memory and mental representation can all contribute to the clinical picture of neglect, which accordingly cannot be traced back to the disruption of a single supramodal process [1,4]. Many of the symptoms traditionally ascribed to left neglect share little in common other than a contra-lesional gradient of increasing impairment, with comparatively well -preserved performance on the ipsilesional (right) side of space [1,5].Although characterising and remediating the clinical condition [1,2,5] are clearly crucial, the primary interest for cognitive neuroscience is how conditions such as visual neglect can inform existing cognitive theory and functional anatomy. That an abnormal bias towards one side of space can exist in the absence of contralateral peripheral sensory or motor loss (e.g. visual field losses or hemi-paralysis) suggests that impairment to higher level processes must be involved. The standard approach taken by cognitive neuropsychology characterises complex mental processes as information-processing systems with separate but interconnected components. Some of the informationprocessing stages involved in visual object recognition (see Fig. 1) illustrate the potential levels and links where lateralised deficits can arise after brain damage.This model charts the processing routes from preattentive assignment of simple structural features (i.e. without the need for focused attention and conscious awareness) to post-attentional integration of local and global processing (involving selective attention and conscious awareness) and the assignment of relevant spatial frames of reference prior to recognition and naming.

The biopsychosocial model outlined in Engel's classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation's International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.

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In early CRPS (type 1), visual input from a moving, unaffected limb re-establishes the pain-free relationship between sensory feedback and motor execution. Trophic changes and a less plastic neural pathway preclude this in chronic disease.

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Normal sensorimotor states involve integration of intention, action and sensory feedback. An example is the congruence between motor intention and sensory experience (both proprioceptive and visual) when we move a limb through space. Such goal-directed action necessitates a mechanism that monitors sensorimotor inputs to ensure that motor outputs are congruent with current intentions. Monitoring in this sense is usually implicit and automatic but becomes conscious whenever there is a mismatch between expected and realized sensorimotor states. To investigate how the latter type of monitoring is achieved we conducted three fully factorial functional neuroimaging experiments using PET measures of relative regional cerebral blood flow with healthy volunteers. In the first experiment subjects were asked to perform Luria's bimanual co-ordination task which involves either in-phase (conditions 1 and 3) or out-of-phase (conditions 2 and 4) bimanual movements (factor one), while looking towards their left hand. In half of the conditions (conditions 3 and 4) a mirror was used that altered visual feedback (factor two) by replacing their left hand with the mirror image of their right hand. Hence (in the critical condition 4) subjects saw in-phase movements despite performing out-of-phase movements. This mismatch between intention, proprioception and visual feedback engendered cognitive conflict. The main effect of out-of-phase movements was associated with increased neural activity in posterior parietal cortex (PPC) bilaterally [Brodmann area (BA) 40, extending into BA 7] and dorsolateral prefrontal cortex (DLPFC) bilaterally (BA 9/46). The main effect of the mirror showed increased neural activity in right DLPFC (BA 9/ 46) and right superior PPC (BA 7) only. Analysis of the critical interaction revealed that the mismatch condition led to a specific activation in the right DLPFC alone (BA 9/46). Study 2, using an identical experimental set-up but manipulating visual feedback from the right hand (instead of the left), subsequently demonstrated that this right DLPFC activation was independent of the hand attended. Finally, study 3 removed the motor intentional component by moving the subjects' hand passively, thus engendering a mismatch between proprioception and vision only. Activation in the right lateral prefrontal cortex was now more ventral than in studies 1 or 2 (BA 44/45). A direct comparison of studies 1 and 3 (which both manipulated visual feedback from the left hand) confirmed that a ventral right lateral prefrontal region is primarily activated by discrepancies between signals from sensory systems, while a more dorsal area in right lateral prefrontal cortex is activated when actions must be maintained in the face of a conflict between intention and sensory outcome.