BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14

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Research Report

The relation between person identity nodes, familiarity

judgment and biographical information. Evidence from two
patients with right and left anterior temporal atrophy

Guido Gainotti⁎, Monica Ferraccioli, Camillo Marra

Center for Neuropsychological Research. Department of Neurosciences of the Policlinico Gemelli/ Catholic University of Rome, Italy

A R T I C LE I N FO AB S T R A C T

Article history: The aim of this study consisted of using neuropsychological data obtained in two patients
Accepted 2 October 2009 (VL and StG) showing a selective atrophy of the anterior parts of the right (VL) and left (StG)
Available online 22 October 2009 temporal lobes to check current cognitive models of familiar people identification.
According to these models, information coming from modality-specific “face”, “voice” and
Keywords: “name” recognition units converge into “Person Identity Nodes” (PINs) where familiarity
Person identification feelings are generated and which provide a modality-free gateway to a unitary semantic
Familiarity system, where information about people is stored in an amodal format. Data obtained in
Temporal lobe atrophy patient VL (and to a lesser degree in StG) were at variance with this model because VL
Face recognition showed: (1) a very impaired familiarity for faces, contrasting with a spared familiarity for
Hemispheric asymmetries names, indicating that familiarity judgments are generated at the level of modality-specific
recognition units and not at a supramodal PIN; (2) a prevalent impairment of person-specific
information available from faces rather than from names also for people that (being
recognized as familiar from both their face and their name) should be normally represented
at the PINs level. This last finding is at variance with the hypothesis assuming that the PINs
may provide a modality-free gateway to a unitary semantic system, where information
about people is stored in an amodal format.
© 2009 Elsevier B.V. All rights reserved.

1. Introduction the formation of a view independent structural description of

All current models of person identification (e.g. Bruce and
Young, 1986; Burton et al., 1990; Valentine et al., 1996; Brédart
et al., 1995; Burton et al., 1999; Young and Burton, 1999) agree
that several cognitive and subjective/behavioural stages are
involved in the process of recognizing and accessing informa-
tion about familiar people. The nature and the sequence of
these stages were first addressed by Bruce and Young (1986)
within a serial cognitive model focused on faces. This model
assumed that identification of a familiar person involves first
a seen face, which could be compared with all the known faces
contained in the Face Recognition Units (FRUs). A similar
process was hypothesized for other channels of people
recognition, such as voices and names (Valentine et al.,
1996), which were deemed to be stored in similar Voice
Recognition Units (VRU) or Name Recognition Units (NRU). The
second step of the people identification process required the
convergence of information stored in these modality-specific
units into person-identity nodes (PINs), allowing identifica-
tion of a particular person and retrieval of the corresponding

⁎ Corresponding author. Neuropsychology Service, Policlinico Gemelli, Catholic University of Rome, Largo A. Gemelli, 8, 00168 Roma, Italy.
Fax: +39 06 3550 1909.
E-mail address: gainotti@rm.unicatt.it (G. Gainotti).

0006-8993/$ – see front matter © 2009 Elsevier B.V. All rights reserved.
doi:10.1016/j.brainres.2009.10.009
104 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –11 4
biographical knowledge. The PINs (or the accessed biograph-
ical information) could, in turn, activate the phonological
codes underlying the production of the person's proper name.
The subjective/behavioural components of the process of
people recognition corresponding to these cognitive stages
concerned first the emergence of a feeling of familiarity for
the addressed person, second the retrieval of people-specific
information (such as occupation, nationality and so on), and
third the retrieval and production of the person's name.
In spite of the general similarities existing among these
models, they differ, however, in two important aspects,
concerning the locus in which familiarity feelings are gener-
ated and in which person-specific information is stored.
Furthermore, controversies exist about the format in which
biographical knowledge is represented. As for the first point,
the Bruce and Young (1986) face identification model assumed
that familiarity feelings may be generated in the recognition
units where the structural description of a seen face is
compared to the familiar faces stored in the FRUs. On the
contrary, in the Burton et al. (1990, 1999), Brédart et al. (1995)
and Valentine et al. (1996) models, decisions about familiarity
are taken at a supra-modal level, namely the PINs, where
information from different modalities is combined in person-
identity nodes. Furthermore, the Bruce and Young's (1986)
model assumes that PINs store semantic information, where-
as Burton et al. (1990, 1999), Brédart et al. (1995) and Valentine
et al. (1996) maintain that PINs do not store semantic
information, but provide a modality-free gateway to a single
semantic system, where information about people is stored in
an amodal format. These last claims are, however, at variance
with results obtained by Snowden et al. (2004) in patients with
semantic dementia, since these authors showed that seman-
tic information accessed through face and name are different,
according to the prevalent side of atrophy. Patients with left
temporal lobe atrophy identified faces better than names and
performed better on the picture than on the word version of
the semantic memory “Pyramids and Palm Trees” test
(Howard and Patterson, 1992), whereas patients with right
temporal lobe atrophy showed the opposite pattern of
performance. Haslam et al. (2004) have objected to the
negative implications that these results could have for the
hypothesis of an amodal format of the person-specific
semantic representation, claiming that a lateralised differen-
tial access to this information might be due to problems at an
earlier stage of processing rather than to a different semantic
representation in the right and left temporal lobes.
Since the anterior parts of the right and left temporal lobes
seem to play a critical role in functions of recognition,
identification and naming of famous people (Eslinger et al.,
1996; Grabowski et al., 2001; Viskontas et al. 2002; Damasio et
al., 2004; Snowden et al., 2004), in a previous review paper
(Gainotti, 2007a) we have tried to see if these controversies
could be clarified by a careful analysis of the patterns of
famous people recognition impairment shown by patients
with right and left anterior temporal atrophy. Results of our
review were consistent with the Bruce and Young (1986)
model, but at variance with the Burton et al.'s (1990, 1999),
Brédart et al.'s (1995) and Valentine et al.'s (1996) hypothesis as
for the locus of familiarity feelings. Two main findings were,
indeed, inconsistent with the assumption that familiarity
judgments may be taken at the PINs level. The first was that
familiarity judgments were much more impaired in right (R)
than in left (L) temporal lobe (TL) patients and the second that
in patients with RTL lesions familiarity defects were modality-
specific, concerning more famous faces than famous names.
These findings suggest that familiarity feelings, being modal-
ity-specific, should be generated at the level of recognition
units and in particular of the FRUs, that could be more
represented in the RTL due to the major role played by the
right hemisphere in face processing (De Renzi, 1986; Michel et
al., 1989; Sergent et al., 1992; De Renzi et al., 1994).
Results of our review were also inconsistent with the
hypothesis assuming that PINs provide a modality-free
gateway to a single system, where semantic information
about people is stored in an amodal format. This disagreement
was due to two main reasons: the first was that patients with a
RTL damage showed an important loss of person-specific
semantic information, which could not be due to a PINs
disruption, because it was greater from face than from name;
the second was that an important imbalance between the
amount of person-specific information available from faces
and names was also found in right and left TL patients who
(showing intact or mildly impaired familiarity judgments),
should have no defect at the PINs level, according to the
previously mentioned cognitive models.
The relevance of results obtained in our review could,
however, be weakened by normative data recently obtained by
Haslam et al. (2004), since these authors have shown that in
normal subjects both familiarity judgments and access to
biographical information are more accurate in response to
names than to faces. Now, since in studies considered in our
review there were usually no normative data, that considered
separately familiarity judgment and biographical information
obtainable from faces and from names, it was possible that the
greater loss of familiarity feelings and of biographical infor-
mation obtained from faces by RTL patients was in part due to
this methodological pitfall. The “normal” advantage of names
over faces documented by Haslam et al. (2004) could also
explain an other partly unexpected result of our review,
namely the fact that LTL patients did not show with names a
greater loss of familiarity and of person-specific semantic
information analogous to that observed with faces in RTL
patients. This asymmetrical pattern could be due to the fact
that in RTL patients the prevalent impairment with faces
could be magnified by the normal advantage of names over
faces, whereas in LTL patients the prevalent impairment with
names could be counterbalanced by the “normal” advantage
of names over faces.
Two very well controlled normative studies, recently
conducted by Bizzozero et al. (2005) and by Bizzozero et al.
(2007) on Italian participants, have allowed us to check if the
differences observed in our review between patients with
right and left anterior temporal atrophy could be mostly due
to the “normal” differences about familiarity judgments and
access to biographical information in response to names and
faces reported by Haslam et al. (2004). In the Bizzozero et al.
(2005, 2007) studies, the influence of age, education and
gender on familiarity recognition and on person identification
from faces and names had been controlled by means of
covariate linear models, partialling out the effect of each
 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14 105

variable and calculating from each subject's raw score the
corresponding adjusted score. In a second step, the adjusted
scores had been classified into five (“Equivalent Scores”)
categories, endowed with an ordinal relationship where
0 = scores lower than the outer 5% inferential tolerance limits;
4 = scores higher than the median value of the sample; 1, 2
and 3 = intermediate scores between the threshold of impair-
ment and the central value of the sample. Possible discre-
pancies between results obtained from faces and names with
this very well controlled procedure could not be attributed to
the “normal” superior performance with famous names
rightly noticed by Haslam et al. (2004). Furthermore, in the
Bizzozero et al. (2005, 2007) studies, the semantic interviews
aiming to assess the person identification were restricted to
the faces and names correctly judged as familiar by the
patient and therefore to people whose PINs should be
unimpaired. Possible discrepancies between results obtained
from faces and names with this procedure should point to a
different format of the semantic representation accessed
through these different channels in patients with right or left
temporal lobe atrophy.
The main scope of the present research, therefore,
consisted in administering the Bizzozero et al. (2005, 2007)
tests of face and name recognition and identification to two
patients (StG and VL), showing a selective mild difficulty of
familiar people identification and naming due to a predom-
inantly right and left temporal lobe atrophy. If the conclu-
sions of our previous review are correct, than, even with this
well controlled material, the RTL patient should show a
greater impairment of familiarity feelings and of access to
person-specific semantic information from faces, whereas a
greater loss of familiarity feelings and of biographical
information from names should not be observed in LTL
patient. If, on the other hand, results of our previous review
were biased by the “normal” asymmetry in familiarity
ratings and access to biographical information stressed by
Haslam et al. (2004), then in RTL subjects we should observe
no name advantage in familiarity judgment or access to
person-specific semantic information and in LTL patients
we could perhaps find a greater deficit from names than
faces, since in the previous uncontrolled study they were
equal.
2. Results
2.1. General neuropsychological assessment
Table 1 reports results obtained by StG and VL on two
successive administrations of the MMSE and of the “Neuro-
psychological Battery.”
In the various columns of Table 1 are orderly reported, from
the left to the right: (a) the test or the component of the test
taken into account; (b) the corresponding cut-off points; (c) the
scores obtained by StG and (d) the scores obtained by VL on
two successive administrations of the tests.
In brackets are reported age and educational level adjusted
scores, whereas in bold are highlighted scores falling below
the cut-off points. Inspection of data reported in Table 1
shows that at the first standard neuropsychological assess-
ment both patients obtain almost completely normal scores,
since only the number of “false alarms” at the RAVLT delayed
recognition exceeds the cut-off point (marginally in patient
VL and more clearly in patient StG). At the second standard
assessment VL obtain completely normal results, whereas
StG shows a significant worsening on tasks of verbal memory
(Immediate and delayed recall of the RAVLT) and of executive
functions (number of “false alarms” at the RAVLT delayed
recognition and Stroop interference time).
2.2. Visual perceptual and spatial abilities
Table 2 reports results obtained by StG and VL on the VOSP.
All results obtained by StG and VL on the “object
perception” and “space perception” components of the VOSP
are normal.

Table 1 – StG and VL performances in two successive examinations of the standard neuropsychological battery.
Cut off StG 01/'07 StG 03/'08 VL 01/'07 VL 04/'08

Mini Mental State Examination 23 28 26 29 28

RAVLT immediate recall 28,53 35 (36,3) 25 (26,3) 52 (53,3) 46 (47,3)
RAVLT delayed recall 4,69 5 (5,6) 2 (2,8) 10 (10,8) 8 (8,8)
RAVLT recognition (hits) 12 15 15 15 14
RAVLT recognition (false alarms) 2 9 12 3 2
Digit span (forward–backward) 5–3 7–4 7–5 6–4 6–4
Rey–Osterreith figure—memory 9,46 7,5 (10) 16 (19,5) 11 (11,5) –
Rey–Osterreith figure—copy 28,87 33 (33) 35 (34,5) 32 (32,5) –
Copying drawings 7,18 8 (7.8) 12(11,4) 10(9,4) 10(9,4)
Copying drawings with landmarks 61,85 67 (66,7) 69 (68,3) 68 (67,3) 68 (67,3)
Raven colored matrices '47 18,96 33 (32,4) 30 (28,4) 29 (27,4) 28 (26,4)
Phonological verbal fluency 17,35 58 (54,9) 46 (39,5) 54 (47,5) 43 (36,5)
Categorical verbal fluency 12 23 20 12 23
Stroop test interference—time 36,92 38 (13.75) 67 (39,5) 42 (12) 43 (18,25)
Stroop test interference—errors 4,24 3 (1.75) 4 (2,83) 0 0

In bold are highlighted scores below the cut-off.

In brackets age and educational level adjusted scores are reported.
106 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –11 4

Table 2 – Performances obtained by StG and VL at the visual 2.4. Associative (“mnestic”) and apperceptive
object spatial perception test (Warrington and James, 1991). (“perceptual”) aspects of face recognition
VOSP Items StG 03/'08 VL 02/'07
Even if only one (VL) of our patients reported some difficulties
Object perception
of familiar people recognition, whereas patient StG only
SCREENING TEST 20 20
1 INCOMPLETE LETTERS 20 20 19 complained of difficulties in finding their names, we thought
2 SILHOUETTES 30 16 17 it useful to administer to both of them the battery of tests
3 OBJECT DECISION 20 18 16 devised by De Renzi et al. (1991) to evaluate the apperceptive
4 PROGRESSIVE SILHOUETTES 20 11 8 and the associative forms of prosopagnosia, to render quite
comparable their study.
Space perception
Results obtained by StG and VL on the “perceptual” and
5 DOT COUNTING 10 10 10
6 POSITION DISCRIMINATION 20 20 20
“mnestic” tests devised by De Renzi et al. (1991) are reported in
7 NUMBER LOCATION 10 7 10 Table 4.
8 CUBE ANALYSIS 10 10 9 Results obtained at the “perceptual” tests of “age estima-
tion” and “face matching” are completely normal at the first
administration in both patients, whereas they become path-
ological at the second administration in patient VL. On the
2.3. General semantic and naming skills and ability to contrary, results obtained at the “associative” tests of “Famil-
name celebrities from photographs and verbal definitions iarity Check” and “Famous faces recognition” are persistently
normal in patient StG, whereas they are pathological both in
Table 3 reports results obtained by StG and VL on the the first and (even more) in the second administration in
“objects naming” and “actions naming” tests, the shortened patient VL.
version of the Snodgrass e Vanderwart's naming test and
the pictorial version of the Pyramids and Palm Trees Test, 2.5. Recognition and identification of famous people from
to evaluate their general semantic and naming abilities and face and name
on the Famous Persons Naming test, to evaluate their
ability to name celebrities from photographs and verbal Table 5 reports the data obtained with the Bizzozero et al.
definitions. (2005, 2007) tests concerning the ability to recognize as
All results obtained by StG and VL on the tests aiming to familiar and to give information allowing the identification
evaluate their general semantic and naming abilities are of famous people from face and name.
clearly within the normal limits. Rather different are results In our analysis of results reported in Table 5, we think it is
obtained by StG and VL on the tests aiming to evaluate their useful to take into account initially data concerning the
ability to name celebrities from photographs and verbal familiarity judgments (first and second administration) and
definitions. With pictorial material, StG obtains a score just then data concerning the biographical information (again first
exceeding the cut-off at the first examination and just below and second administration).
it at the second examination, whereas VL obtains in both
cases a pathological performance. With verbal semantic 2.5.1. Familiarity judgments from faces and names
definitions, StG still obtains a score just exceeding the cut- When familiarity judgments from faces and names are taken
off at the first examination, but falls well below that point at into account at the first administration of the tests, a double
the second examination, whereas VL obtains in both cases a dissociation can be found between patients StG and VL. StG
normal performance. Taken together, these data show a obtains from faces an equivalent score of 4, higher than the
dissociation between StG and VL, because the former obtains median value of the control subjects and with names an
similar results from photographs and verbal definitions, equivalent score of 2, intermediate between the central value
whereas the latter obtains pathological performances only and the threshold of impairment, whereas VL obtains from
from photographs. faces an equivalent score of 0, lower than the outer 5%

Table 3 – Performances obtained by StG and VL at the tasks examining their general semantic and naming skills and their
ability to name celebrities from photographs and verbal definitions.
Cut off StG 01/'07 StG 03/'08 VL 01/'07 VL 04/'08

Objects naming 28 30 30 29 30
Actions naming 26 28 28 28 26
Snodgrass
(errors: living–non living) 74 77 (2–1) 77 (2–1) 79 (0–1) 75 (4–1)
Pyramids and Palm Trees Test 47 52 52 51 49
Famous People Naming test by photo 31.7 32/45 31/45 30/45 30/45
Famous People Naming test by definition 33.3 33/45 27/45 38/45 34/45

In bold are highlighted scores below the cut-off.

 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14 107

Table 4 – Performances obtained by StG and VL on the tests devised by De Renzi et al. (1991) to evaluate perceptual
(“apperceptive”) and mnestic (“associative”) aspects of face recognition.
Items StG 03/2007 StG 03/2008 VL 06/2007 VL 02/'08

AGE DISCRIMINATION—raw scores 48 4 6 8 22

AGE DISCRIMINATION—standard scores −0.3387 0.1190 0.5766 3.7803
AGE DISCRIMINATION—correct scores −0.9487 −0.4910 − 0.1233 2.9303
FACE MATCHING TEST – raw scores 27 5 3 9 11
FACE MATCHING TEST—standard scores −0.0372 −0.7807 1.4498 2.1933
FACE MATCHING TEST—correct scores −0.4972 −1.2207 0.9098 1.4633
FAMILIARITY CHECK—raw scores 36 4 3 14 18
FAMILIARITY CHECK—standard scores −0.3840 −0.5789 1.5653 2.3450
FAMILIARITY CHECK—correct scores 0.2560 0.2411 2.2953 2.7150
FACE IDENTIFICATION—raw scores 32 2 3 7 11
FACE IDENTIFICATION—standard scores −0.1006 0.2043 1.4238 2.6433
FACE IDENTIFICATION—correct scores 0.5594 1.0043 2.1538 3.0933

Error score: In bold are highlighted scores below the cut-off.

inferential tolerance limits and from names a score of 3, just
below the median value of the normal subjects.
This dissociation becomes much less evident at the second
administration of the Bizzozero et al. (2005, 2007) tests,
because in this case patient StG obtains the same familiarity
score (3) with faces and names, and patient VL still obtains an
equivalent score of 0 from faces, but worsens from (3) to (2)
with names.
2.5.2. Biographical information drawn from familiar faces
and names
The evaluation of biographical information was conducted
only on faces and names judged as familiar by patients StG
and VL. In this last patient, all people considered as familiar
from face had been considered as familiar from name too.
Even on this more restricted number of famous people, VL
showed, on both administrations of the Bizzozero et al. (2005,
2007) tests, a dissociation between results obtained from faces
and from names, because with names he obtained an
equivalent score of 2 (intermediate between the central
value and the threshold of impairment), whereas with faces
her score was again of 0. On the other hand, StG, who during
her first examination had not completed the semantic part of
the Bizzozero et al. (2007) proper name comprehension test,
obtained overall a slight advantage in drawing semantic
information from faces, scoring (2) on the first and (1) at the
second administration, than from names, scoring (0) at the
second administration of the test.
The dissociation between results obtained from faces and
from names by patient VL was theoretically important, because
it showed that patients with right anterior temporal lesion can
show a greater person-specific semantic impairment from face,

Table 5 – Performances obtained by VL and StG at the test of recognition and identification of famous people from face and
name (Bizzozzero et al., 2005, 2007).
StG VL

03/2007 03/2008 02/2007 02/2008

Famous people photos

Hits 46 47 29 34
False 2 1 4 9
Familiarity Raw scores 7666 7568 6072,5 6350
Corrected scores 7554,5 7456,5 5961 6274,44
Equivalent scores (4) (3) (0) (0)
Semantic definition (raw score / max score) 227/276 219/282 113/174 144/204
Semantic Mean score 4,935 4,66 3,896 4,235
Corrected score 4,739 4,464 3,908 4,205
Equivalent score (2) (1) (0) (0)

Famous people names

Hits 62 62 60 62
False 1 1 1 3
Familiarity Raw scores 7865,5 7944 7923,5 7906
Corrected scores 7810,77 7939 7868,77 7851,27
Equivalent scores (2) (3) (3) (2)
Semantic definition (raw score/max score) – 289/372 300/360 309/372
Semantic mean score – 4,66 5 4,9839
Corrected score 4,434 4,898 4,9069
Equivalent score (0) (2) (2)
108 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –11 4
even if we limit the study of biographical information to people
whose PIN should be intact (being recognized as familiar from
both their face and their name). Limiting our comparison to
the equivalent scores, it was, however, difficult to say if this
dissociation was statistically significant. We, therefore, com-
puted for VL the amount of semantic information available for
each familiar face and name (the range being between 0 and 6
for each item, as reported in the methodological section) and
we decided to make a more direct comparison between the
amount of biographical information from these modalities in
both the first and the second administration of the Bizzozero
et al. (2005, 2007) tests.
In the first administration VL obtained a mean value of
biographical information of 4.03 (SD = 1.93) for each face and of
5.27 (SD = 0.96) for each name. This difference was highly
significant at the statistical control (t = 3.32; p < .003). Similar
results were obtained at the second administration, because
the mean value of biographical information was of 4.23
(SD = 1.53) for faces and of 5.12 (SD = 1.06) for names (t = 3.54;
p < .001).
3. Discussion
Results of the present study are clearly in line with those of
previous investigations that have tried to identify the brain
areas selectively contributing to person recognition and
naming. These research issues have been studied in consider-
able detail in previous work, based on a fairly large number of
subjects (e.g. Tranel et al., 1997; Damasio et al., 2004; Tranel,
2006), showing that atrophy of the right and left anterior
temporal lobes provides the basis respectively for famous
person recognition and naming. Furthermore, the “conver-
gence zone” framework of Damasio (1989) and Damasio et al.
(2004) and the extended convergence zone model, set for by
Barsalou et al. (2003), have inserted these data into a
stimulating and convincing theoretical framework. Results of
our study, which aimed to investigate the implications that the
above mentioned neuro-anatomical models could have with
respect to cognitive models of familiar people identification,
allowed us to advance two clear assumptions about the
relations between person identity nodes, familiarity judgments
and person-specific semantic representations and a third
assumption, concerning the format in which person-specific
semantic representation is represented in each hemisphere.
As for the familiarity judgments, our data clearly show that
the corresponding decisions are not taken at a supra-modal
level, namely at the PINs level, as suggested by the Burton et
al. (1990, 1999), Brédart et al. (1995) and Valentine et al. (1996)
models, but in the modality-specific recognition units where
the structural descriptions are compared to the corresponding
stored representations. Our data strongly support, in partic-
ular, the Bruce and Young (1986) face identification model,
which assumes that familiarity feelings may be generated in
the recognition units where the structural description of a
seen face is compared to the familiar faces stored in the FRUs.
Furthermore, our results add to this cognitive model the
anatomical suggestion that the RTL structures play a critical
role in this process. Our patient VL, with right anterior
temporal atrophy, showed, indeed, on both administrations
of the Bizzozero et al. (2005, 2007) tests a striking dissociation
between a disrupted generation of familiarity feelings from
famous faces (obtaining in each case an equivalent score of 0),
and a relatively spared generation of familiarity judgments
from names, obtaining on the first administration a score of 3,
just below the median value of the normal subjects and on the
second administration a score of 2, intermediate between the
central value and the threshold of impairment. Our data
concerning the recognition units and their anatomical sub-
strates are, however, less striking when we pass to analyse the
familiarity feelings generated by a famous people's name. Our
patient StG, with left anterior temporal atrophy, obtained,
indeed, on the first administration a dissociation between
intact familiarity from faces (equivalent score of 4) and rather
poor familiarity from names (equivalent score of 2), but
showed on the second administration the same familiarity
score (3) with faces and names. Results obtained with a very
well controlled test in our patients VL and StG are, therefore,
quite similar to those obtained in our previous review of the
patterns of famous people recognition disorders observed in a
group of (less carefully controlled) patients with right and left
anterior temporal lesions (Gainotti, 2007a). Just as in the
present study, also in that review, defective familiarity
feelings concerned more frequently and more severely face
than name in patients with right anterior temporal lobe
damage, whereas they were less severe and more evenly
distributed between face and name in patients with left
anterior temporal lobe lesions. This asymmetry between the
mechanisms underlying the generation of familiarity judg-
ments for face and name is probably due to the different
nature of these two sorts of stimuli. It is, indeed, likely that the
neural network necessary for the generation of familiarity
feelings for a complex perceptual structure, such as the
human face requires a dedicated structure located at the end
of the visual processing stream and preferentially represented
in the right hemisphere for reasons that I have tried to clarify
in a previous review of this subject (Gainotti, 2007b). On the
other hand, the generation of familiarity judgments for a
famous name could require a less complex and less strongly
lateralized neural network.
Also our data concerning the person-specific semantic
representation are at variance with the models proposed by
Burton et al. (1990, 1999), Brédart et al. (1995) and Valentine et
al. (1996), which maintained that PINs do not store semantic
information, but provide a modality-free gateway to a single
semantic system, where information about people is stored in
an amodal format. As a matter of fact, if PINs are simply a
modality-free gateway to a unitary person-specific semantic
system, then, irrespectively of the side of temporal lobe
damage, the same amount of semantic information should
be obtained in response to face and name of people whose
familiarity is relatively intact. However, data obtained in our
patients StG and VL do not support this prediction.
At a first more global level of analysis, conducted on the
equivalent scores of biographical information relative to
people judged as familiar from both faces and names, our
patients, VL showed, on both administrations of the Bizzozero
et al. (2005, 2007) tests, a better score from names (where he
obtained an equivalent score of 2) than from faces (where his
score was 0).
 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14
In a second, more detailed analysis, in which we computed
for VL the amount of semantic information available for each
familiar face and name (the score ranging between 0 and 6 for
each item) we again obtained a significantly greater amount of
person-specific semantic information from name than from
face in both the first and the second administration of the
Bizzozero et al. (2005, 2007) tests. These data clearly show that
PINs are not simply a modality-free gateway to a unitary
person-specific semantic system, because in our patient VL
with a right anterior temporal lobe atrophy the amount of
available biographic information was greater from name than
from face, even for people whose PIN was intact. A similar, but
inverse pattern, with slightly greater amount of biographic
information available from face than from name was observed
in a patient (StG) with left anterior temporal lobe atrophy. As
for the generation of familiarity judgments, also for the
retrieval of biographical information, results obtained in the
present study confirm those obtained in our previous review
(Gainotti, 2007a). Even in that paper, the ratio between the
amount of person-specific information available from faces
and names was more imbalanced in right than in left anterior
temporal patients. The former showed a significantly greater
difficulty accessing person-specific knowledge from faces
than from names, whereas in the latter the semantic loss
tended to be only slightly greater from names than from faces.
In any case, data of the present study show that the often
reported differences between patients affected by a RTL
damage and those with LTL lesions for familiarity judgement
and biographical information obtainable from faces and from
names cannot be due to the “normal” advantage of names
over faces in familiarity ratings and access to biographical
information as suggested by Haslam et al. (2004). These
differences, indeed, persisted even when these possible
confounding factors had been controlled using the very well
careful normative data offered by Bizzozero et al. (2005, 2007).
At this point of the present discussion, we would stress the
fact that results of our investigation have been discussed with
reference to cognitive models, only because our study had
been designed to check these models, but that our results are
also consistent with those of investigations that have tackled
the problem of people recognition disorders with different
(neuroanatomical) models and with a different terminology.
In particular, we refer here to results obtained with the
neuroanatomical model by authors of the Iowa group (Dama-
sio et al., 1996; Tranel et al., 1997; Damasio et al. 2004, Tranel,
2006; Drane et al., 2008) who have used the term “recognition”
to denote the presence of “familiarity feelings” and the term
“identification” to denote a correct retrieval of person-specific
semantic information. These authors have shown that
defective recognition of familiar people is associated with
maximal lesion overlap in the right temporal polar region
(Tranel et al., 1997; Damasio et al., 2004; Drane et al., 2008),
whereas a proper name anomia is typically observed in
patients with lesions encroaching upon the anterior parts of
the left TL (Damasio et al., 1996, 2004; Tranel, 2006; Drane et al.,
2008). These results were interpreted by assuming that the
nondominant anterior TL may play a major role in binding
sensory information into conceptual percepts for certain
stimuli, while dominant TL regions function to provide a link
to verbal labels for these percepts. This viewpoint is very
109
similar to the Gainotti's (2007a) “different format hypothesis”
that assumes that the right hemisphere knowledge might be
substantially based upon a convergence of perceptual infor-
mation, in which the visual data play the major role, whereas
the left hemisphere knowledge might be based on a more
balanced and complex integration between sensori-motor and
linguistic information, mainly oriented toward the naming
mechanisms. This similarity stems from the fact that, in
agreement with the Damasio's (1989, 1990) model of the
higher-order convergence zones, the “different format hy-
pothesis” views the semantic network as resulting from the
recollection of modality-specific memories, stored near the
sensory portals and motor output sites of the system. This
hypothesis, therefore, assumes that a different format of the
right and left semantic representations should correspond to
the different weight of the perceptual, motor and linguistic
information processed by each hemisphere.
An alternative version of this interpretation could consist
in assuming that the processing of perceptual information
(and in particular the mechanisms underlying the face
recognition and the face-voice integration) may play a major
role in the right temporal structures, whereas an integration of
perceptual, linguistic and action-related features, oriented
toward the operations of name retrieval and name production,
may characterize the left semantic structures. According to
this hypothesis, strong connections between visual-perceptu-
al and conceptual activities could characterize the right
hemisphere semantic system, whereas important links be-
tween conceptual knowledge and lexical output mechanisms
could characterize the left hemisphere semantic organization.
A recent support to these interpretations has been
provided by Acres, Taylor, Moss, Stamatakis, and Tyler (2009)
who have tested the hypothesis that the left inferior temporal
lobe may mainly link conceptual information with word
forms, whereas the right inferior TL may mainly support the
retrieval of conceptual knowledge from visual input. To test
this hypothesis, Acres et al. (2009) administered two verbal
and two visual tasks to 15 patients with TL damage and
correlated their behavioural scores with voxel-based mea-
sures of neuronal integrity. Their results supported the notion
of complementary hemispheric advantages for object naming
and visual recognition, because performance on verbal tasks
correlated with the neural integrity of the left inferior and
anterior TL regions, whereas performance on visual object
recognition correlated with the neural integrity of the right
inferior and anterior TL cortices. The hypothesis of a different
structure of person-specific knowledge at the level of the right
and left temporal lobes, obviously does not imply that we
know different things about Bill Clinton when we see his face
or hear his name. It simply implies that the information
asymmetrically represented on the two sides of the brain are
systematically and continuously integrated through the
callosal connections, just as are systematically integrated
many other abilities for which hemispheric asymmetries are
usually acknowledged. In pathological conditions, however,
lesions in the right and left anterior TL could disrupt two
different potential paths to person-specific information (i.e.,
access by name or access by perceptual features, depending
on the side of dysfunction), leading to different patterns of
familiar people recognition disorders.
110 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –11 4
4. Experimental procedures
4.1. Methods
All patients were given a series of tests aiming to evaluate: (a)
the general neuropsychological background, (b) the visual
perceptual and spatial abilities, (c) the general semantic and
naming abilities, (d) the ability to name celebrities from
photographs and verbal definitions, (e) the apperceptive and
associative aspects of face recognition, (f) the recognition and
identification of famous people from face and name.
4.1.1. Background Neuropsychology
The general neuropsychological background was assessed with
the Mini Mental State Examination (MMSE) and the “Neuropsy-
chological Battery,” that has been described in detail in previous
papers (e.g. Gainotti et al., 2001) and will be only shortly
described here. It is based on tests of episodic long term verbal
memory [Rey's Auditory Verbal Learning Test (RAVLT): imme-
diate (IR) and delayed recall (DR) and delayed recognition ],
(Lezak, 1995), long term visual-spatial memory [Rey–Osterreith
Complex Figure delayed reproduction (ROCFR)] (Lezak, 1995),
immediate verbal and visual-spatial memory (Digit and Spatial
Span), limb, oral and constructional praxis (Rey–Osterreith
Complex Figure copy (ROCFC) and drawing designs with and
without landmarks), phonological and semantic/categorical
verbal fluency, and the Raven's Progressive Matrices, consid-
ered as a visual deductive reasoning task. The “Battery” also
includes a group of tests sensitive to frontal lobe lesions, such as
a demanding attentional task (Multiple Features Targets Cancel-
lation/MFTC) (Gainotti et al. 2001), a test of temporal rules
induction (Villa et al., 1990) and the Stroop interference test.
4.1.2. Visual perceptual and spatial abilities.
The visual perceptual and spatial abilities were studied with the
“Visual Object and Space Perception” (VOSP, Warrington and
James, 1991), that includes subtests of object perception
(incomplete letters, silhouettes, object decision and progressive
silhouettes) and subtests of space perception (dot counting,
position discrimination, number location and cube analysis).
4.1.3. General semantic and naming abilities and ability to
name celebrities from photographs and verbal definitions
The general semantic and naming abilities were evaluated
with the “naming objects” and “naming actions” subtests of
the BADA (Miceli et al., 1994), with a shortened 80 items version
of the Snodgrass e Vanderwart's set of pictures and with the
pictorial version of the Pyramids and Palm Trees Test (Howard
and Patterson, 1992). On the other hand, the ability to name
celebrities from photographs and verbal definitions was
studied with the Famous Persons Naming test (Benaglio,
Cappa and Semenza, unpublished), which contrasts the
capacity to name 45 celebrities from presentation of a
photograph and from a short verbal definition.
4.1.4. Associative (“mnestic”) and apperceptive (“perceptual”)
aspects of face recognition
The apperceptive and associative aspects of face recognition
were assessed with the battery of tests devised by De Renzi et al.
(1991) to evaluate the apperceptive and the associative forms of
prosopagnosia. This battery consists of two unfamiliar faces
tests (also referred as “perceptual” tests by De Renzi et al., 1991)
and two famous faces tests (also referred as “mnestic” tests by
De Renzi et al., 1991). The first “perceptual” test is the Levin et al.
(1975) short form of the Benton and Van Allen's (1968) Face
Matching Test, which consists of showing the patient a
photograph of an unfamiliar face, requiring the patient to
match this face with other views of the same face (photographed
from different perspectives), presented amongst similarly lit
views of different faces. The second perceptual test is the De
Renzi et al. (1989) Age Estimation Test, in which the patient is
presented with 12 cards, each containing four photographs of
faces of the same sex, but of different age with the instruction to
point to the youngest and the oldest face. The first “mnestic”
famous faces test is the Familiarity Check Test (De Renzi et al.,
1991), in which the subject is presented with 36 cards, containing
four faces of people (one famous and 3 anonymous) of the same
sex and age, and requested to point to the more familiar face.
The second mnestic face test is the Famous Face Recognition
Test (De Renzi et al., 1991), which consists in presenting the
subject with 32 cards, each containing four famous faces of the
same sex and category (e.g. four actors), asking him/her to point
to the face corresponding to the name provided by the examiner.
Only one face/name per display was tested.
4.1.5. Recognition and identification of famous people from
face and name
The ability to recognize as familiar and to give information
allowing the identification of famous people from face and
name was studied with the Bizzozero et al. (2005, 2007) tests.
These authors administered to 98 normal subjects two perfectly
equivalent face (Bizzozero et al., 2005) and written name
(Bizzozero et al., 2007) versions of a test, consisting of 126 Italian
and foreign faces and proper names. One half of these stimuli
belonged to famous people and 63 represented unfamiliar faces
or corresponded to fictitious, but phonemically plausible names.
Celebrities had been selected according to two main criteria: 1.
the period of their fame (before War World II; after War World II
or in the last 30 years) and 2. their professional category
(entertainment, culture or politics). Each fame period and each
professional category accounted for 21 (1/3) of the famous
persons. In the “fame recognition” test, the relative difficulty of
each item was determined according to the number of the
participant's failures with each individual face and name, and
all (face or name) stimuli were ranked from the most difficult to
the easiest ones. Thus, the face and the name that yielded the
largest number of failures obtained a rank score of 1.0, whereas
those that yielded the smallest number of errors obtained a rank
score of 126.0. In the “person identification” test, only faces and
names previously recognised as familiar were examined. Items
differed, therefore, in type and number across participants and
recognition modalities. To evaluate person identification,
participants were requested to answer a semantic interview,
concerning (1) the time in which the person was famous (before
World War II; after World War II or in the last 30 years); (2) the
professional category to which he/she belonged (entertainment,
culture or politics); (3) any other information allowing the
identification process. For each of these questions the score
ranged between 0 and 2; therefore the overall semantic score
 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14 111

obtainable from each face or name ranged between 0 and 6. As
we told in the introduction, raw scores were then transformed
into adjusted scores, partialling out the influence of age,
education and gender and adjusted scores were classified into
five (“Equivalent Scores”) categories, endowed with an ordinal
relationship where 0 corresponded to scores lower than the
outer 5% inferential tolerance limits and 4 to scores higher than
the median value of the sample.
4.2. Patients
4.2.1. Patient VL
4.2.1.1. Clinical aspects. VL is a 72 years retired old man, with
a doctoral degree in law and married with two sons. He comes
from the southern part of Italy, but he is living from about 40
years in Rome, where he has worked as manager of a public
company. In December 2006 he consults our Neuropsychology
Service, reporting mild memory difficulties, noticed since some
months. There is no familiar or personal history of neurological
or psychiatric disorders, the neurological examination is normal
and the only reported medical disease is an important bradyar-
rhythmia. During the first neuropsychological examination,
carried out in January 2007 and which shows only a defect of
familiar people identification, neither the patient nor his wife
spontaneously report defects of this kind, but when specifically
requested, acknowledge that since a couple of years VL presents
some difficulty in the recognition of not very acquainted people.
In May 2007 a pacemaker has been implanted, with good results,
for the control of the patient's bradyarrhythmia. During the
following months the patient has shown a worsening of the
familiar people recognition disorders, a mild impairment of
episodic memory and a progressive personality change, with
irritability, obstinacy and more dependent behaviour. Further-
more, the wife reports a change in alimentary habits, with a
tendency to eat more than usual. During the second neuropsy-
chological examination, carried out in April 2008, however, the
patient's behaviour is appropriate and he acknowledges his
difficulties in the recognition both of familiar faces and of
familiar voices when he answers to the telephone. The
neurological examination is still normal, but the patient
presents a psychomotor slowing and a rather depressed mood.
After the last assessment the wife of the patient has reported 3
episodes of topographical disorientation with difficulty to recall
the road pursued. All these episodes followed situations of
physical stress, after long travels with the car or walking.
4.2.1.2. Neuroimaging. Structural (MRI) and functional
(SPECT) neuro-radiological data were highly consistent in VL,
since an MRI obtained in October 2006, just before the pace-
maker placing, showed a bilateral atrophy of the ventral and
mesial parts of the temporal lobes, definitely more pronounced
on the right side (Fig. 1), whereas a SPECT (single photon
emission computed tomography) scan in January 2007 (Fig. 2)

Fig. 1 – CDMRI. Axial FLAIR T2-WI. There is obvious atrophy in the ventral temporal lobes bilaterally, associated with evident
signal modification involving the right temporo-mesial cortex. Volume loss is definitely more pronounced in the right side,
where middle cranial fossa subarachnoid spaces and anterior temporal horns are markedly dilated. Note also moderate dilation
and prominent sulci along right lateral temporal lobe.
112 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –11 4

Fig. 2 – 99mTechnetium Ethyl Cysteinate Dimer Single Photon Emission Tomography (99mTc-ECD SPET) of the brain.
The transaxial slices, oriented according the temporal long axis, show a severe hypoperfusion in the anterior and inferior
parts of the right temporal lobe extending to the posterior part of the lateral temporal cortex and to a lesser extent in the mesial
part of the left temporal lobe.

Fig. 3 – CT scan: a mild atrophy in the ventral temporal lobes bilaterally. Volume loss is moderately more pronounced in the left
side, where middle cranial fossa subarachnoid spaces and anterior temporal horns are markedly dilated.
 BR A I N R ES E A RC H 1 3 0 7 ( 2 01 0 ) 1 0 3 –1 14
Fig. 4 – 18Fluoro-deoxy glucose positron emission tomography (18F-FDG PET) of the brain. The transaxial slices (oriented
according the temporal long axis) show a severe hypometabolism in the anterior, and lateral inferior parts of the left temporal
lobe extending to the dorsal area of the mesial temporal regions.
showed a much more extensive hypoperfusion affecting
ventral and dorsal parts of the right temporal lobe.
4.2.2. Patient StG
4.2.2.1. Clinical aspects. StG is a 69-year-old retired old
woman, who has worked in High Schools as foreign languages
teacher (French and German). Born in the northern part of Italy,
she is living in Rome from more than 30 years. In January 2007
she consults our Neuropsychology Service, reporting mild
difficulties in finding proper names of people and in performing
arithmetic operations. She also reports some difficulties of
sustained attention or concentration. Her anxiety for these
disorders is increased by the fact that she has a familiarity for
degenerative forms of brain disease, since, on the maternal side,
the patient's mother and her sister have shown a senile
dementia, characterized by slowly evolutive memory and
cognitive disorders. A CT scan (Fig. 3) was performed at the
time of her first consultation, whereas it was not possible to
obtain a brain MRI, due to the presence of para-magnetic
osteosynthesis subsequent to a left shoulder bone fracture.
During the first neuropsychological examination, carried
out in January 2007, she obtains normal scores on all the tests
administered, with the exception of mild defects on tests of
verbal memory and of famous people naming. During the
following months the patient has shown a slight worsening of
these difficulties and has developed an important anxiety
reaction, tied to the embarrassment resulting from the
difficulty to remember the people's names or the details of
recent events. A mild worsening of the previously described
113
patient's difficulties and of her anxious state was observed
during the second neuropsychological examination, carried out
in March 2008. In January 2009 a FDG PET scan was performed.
4.2.2.2. Neuroimaging. The CT scan (Fig. 1) showed a mild
bilateral atrophy of the ventral and mesial parts of the
temporal lobes, slightly more pronounced on the left side,
whereas the FDG PET (2-deoxy-2-[F-18]fluoro-D: -glucose
Proton Emission Tomography) scan (Fig. 2) showed a much
more extensive hypometabolism affecting polar, ventral and
infero-lateral parts of left temporal lobe. A less evident
hypometabolism was also observed in the dorsal parts of the
left temporal lobe (Fig. 4).
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