Document KLoZy4vjDLLn40a5jyybGZo2

Neuropsychological Assessment Second Edition MURIEL DEUTSCH LEZAK Oregon Health Sciences University and Veterans Administration Hospital Portland, Oregon New York Oxford OXFORD UNIVERSITY PRESS 1983 A COMPENDIUM OF TESTS AND ASSESSMENT TECHNIQUES Table 11-7 Phonetically Regular Words Adventurously Individual Uninterested Experimenter Apprehensive Indtsooverable Manufactured Organizations Particularly Trajectory Chilterling Herpetology Fleeringly Huckaback interlergal Tipulariari Gressorial Paraboloid Hectographic Shibboleth (Adapted from Nelson and O'Connell, 197S) Table 11-8 The New Adult Reading Test Ache Debt Psalm Depot Chord Bouquet Deny Capon Heir Aisle Subtle Nausea Equivocal Naive Thyme Courteous Gaoled Procreate Quadruped Catacomb Superfluous Radix Assignate Gist Hiatus Simile Aeon Cellist Zealot Abstemious (Adapted from Nelson and O`Connell, 1978) Couge Placebo . Faade Aver Leviathan Chagrin Detente Gauche Drachm Idyll Beatify Banal Sidereal Puerperal Topiary Demesne Labile Phlegm Syncope Prelate Questions are on tape, but the subject can write his answers at his own pace. Available norms only make discriminations between functionally literate, marginally literate, and illiterate, so that this test is more useful for limited practical purposes than for clinical ones. R eading C omprehension-- Simple Commands (A. Smith, no date) The five-sentence reading subtest of The Michigan Neuropsychological Battery (see p. 572) consists of cards, each with a simple command written on it, such as, "Put the lock in the cup"; "Close your eyes and touch your nose." Reading comprehension is reflected in the patient's motor responses. Gross screening tests such as this need no norms. Should a patient fail to perform the commands satisfactorily, the examiner must then analyze the reading disability in terms of its basic elements (e.g., form recognition, visual scanning, verbal comprehension, etc.) to determine the nature of the disability. Writing and Spelling Qualitative aspects of writing may distinguish the script of patients whose brain dam age is lateralized (Brodal, 1973; Hecaen and Marcie, 1974). Patients with right hemi- 338 ^UES puLriaii essorul .raboloid ^olographic ihbnlelh Beatify Banal Sidereal Puerperal Topiary Demesne Labile Phlegm Syncope Prelate "iV ,,s: \.-XST'V:i `Of & VERBAL FUNCTIONS sphere lesions tend to repeat elements of letters and words and to leave a wider than normal margin on the left-hand side of the paper. Left visuospatial inattention may be elicited by copying tasks (see Fig. 11-1). Edith Kaplan has called attention to "little perseverative errors' in the writing of patients with right brain lesions, such as extra bumps on n's"and" m s. Patients with left hemisphere lesions are more likely to have a wide right-sided margin and tend to leave separations between letters or syllables that disrupt the continuity of the writing line. Kaplan has also noted that aphasic patients tend to print when asked to write. In studying the writing disturbances of acutely confused patients, Chedru and Geschwind (1972) devised a three-part writing test: (I) writing to command, in which patients were told to write a sentence about the weather and a sentence about their jobs; (2) writing to dictation of words (business, president, finishing, experience, phy sician, fight) and sentences ("The boy is stealing cookies." "If he is not careful the stool will fall.''); and (3) Copying a printed sentence in script writing ("The quick brown fox jumped over the lazy dog.''). They found that the writing of these patients n pace. Available irginally literate, mrposes than for no date) gical Battery (see . such as, "Put the comprehension is h as this need no ily, the examiner ments (e.g., form line the nature of whose brain dams with right hemi- Fig. 11-1 This attem pt to copy an address was made by a 66-year-old retired papermill worker two years after he had suffered a right frontal CVA. His writing not only illustrates left visuospatial inattention, but the tendency to add "bum ps" (e.g., the m in "James") a nd impaired visual tracking (e.g., "Ave`` is repeated on the line below the street address line)-- all problems that can interfere with the reading and writing of patients with right hemisphere lesions. VEHHAL FUNCTIONS was characterized by dvsgruphiu in the form of nmlor impairment (e.g., scribbling), spatial disorders (eg., of aligninenl, overlapping, cramping), agrammatisms, and selling and other linguistic errors. Moreover, dysgraphia lend! to be the most prom* inent and consistent behavioral symptom display! by them. The authors suggest that the fragility of writing stems from its dependence on so many different components of behavior and their integration. They also note that for most (>eople. writing, unlike speaking, is far from an overlearned or well-practiced skill. Sentence Building (subtest of the Stanford-Binet scales, year SA I) (Terman and Merrill, 1970) This task requires the patient to compose a sentence around three given words. It is sensitive to slight impairments of verbal functions that may show up in occasional speech hesitancies or neologisms but are not reflected in significantly depressed WAIS verbal subtest scores. Sentence Building can be given as a written test, either as part of a paper and pencil test battery in which the instructions and words are printed on an answer sheet, or it can be orally administered with the request to "write" the sentence. Besides testing verbal and sequential organizing abilities and use of syntax, the written format elicits spelling, punctuation, and graphomotor behavior. A written form of this subtest is included in my paper and pencil test packet for neuropsycho logical assessment (see pp. 108-109). The 1937 revision, Form M version of the Sen tence Building subtest at age level VII broadens the applicability of this test to adults with limited verbal skills. A five-item version of this task using two or three words is included in the Neuro psychological Test Battery developed by Miceli and his colleagues (Miceli et al., 1977, 1981). A scoring system takes into account both production of meaningful sentences that are grammatically correct (3 points each) and response time (1 point for sen tences composed within 20 seconds, 2 points if response time is ten seconds or less). Performances of nonaphasic patients with left hemisphere lesions and of patients with right hemisphere lesions did not differ on the basis of their scores. Writing and spelling can be readily assessed by questions requiring written responses such as those of the paper and pencil test battery that I use (see Fig. 11-2 and pp. 108-109). A self-report questionnaire, the Personal History Inventory (PHI) (Lezak, 1968), also provides incidental information about the patient's reading and writing skills. 341 ES o explore the s. whether the or movement, ire most likely stress, fatigue, the examiner the patient at suspected, for or complexity, y to give very oses it may be /, shading into of abstraction upon mental '/ Objects test vity in bright as he can for r. Two examor "Pencil-- 're uses to be esponses such >r the "right" .nking, on the i daring ideasorrect or logck for a bednental inflexr on the main Tobable uses, iple of classi- eveloped as a ;) also can be 'rial, the subior nameable After being ;* given fiveas they can, uf each type i draw ing so trial is the >) four lines. -sfc EXECUTIVE FUNCTIONS AND MOTOK PERFORMANCES straight or curved. Again the subject is shown acceptable and unacceptable examples and the instructions place emphasis on the subject s making as many different draw ings as possible. The control subjects'average output on the free five-minute condition was 16.2 designs, on the fixed (four-minute) condition it was 19.7. Approximately 10% of their responses were judged perseverative. Frontal lolie patients tended to have reduced output on both free and fixed conditions relative to normal subjects and patients with posterior lesions. Patients with right-sided lesions generally tended to have lower productivity (except right posterior patients on the free condition), and those with right frontal lesions were least productive. Patients with frontal--partic ularly right frontal--and right central lesions showed the greatest tendency to per severation relative to the control group on both free and fixed conditions. Perseverative behavior is one of the hallmarks of response inflexibility. When per severation or difficulty in shifting is suspected, the patient can be asked to copy and ^maintain alternating letters (e.g., mnmnmrt in script) or repetitive sequential patterns of hand movements (see also pp. 522-523) with separate trials for each hand to deter mine whether there are laterality differences in hand control (e.g., see Christensen, 1979; Luria, 1966; pp. 567-568). Luria (1966) gave patients a sheet of paper with several word series typed in rows such as "circle, circle, circle, cross, circle" or "square, cross, circle, cross, cross," with instructions to draw the indicated figure below each word as fast as possible. Similar chains of verbal commands also elicit' perseverative tendencies. A variety of figures can be named, including the simple geometric forms, letters, and numbers. Of the common geometric figures, circles are least likely, squares more likely, and triangles most likely to be perseverated (E. Gold berg, 1975). E. Goldberg and David Tucker (1979) have identified four types of per severation that can occur in simple drawing responses to these kinds of chained verbal commands: (1) "Hyperkinetic-like motor perseveration" refers to inability to termi nate an elementary movement that, on a drawing, shows up in multiple overdrawings of single elements of the task or continuation of an element until stopped by the edge of the page. (2) In "perseveration of elements," the patient can reproduce discrete elements but introduces elements of previously drawn figures into subsequent ones. (3) "Perseveration of features" involves the perpetuation of some characteristic of a previously drawn figure, such as "openness," which produces, for example, a cross drawn in outline following an outlined ("open") figure such as a circle or a crescent rather than the more usual form of intersecting lines. (4) In "perseveration of activi ties," different categories of stimuli, for example, words and numbers, mathematical and geometrical symbols, become confounded. These authors point out that only type I is a true motor perseveration. The other types result from breakdown of cognitive processing at different levels, from unification of the elements in different graphic sequences (2), to confusion of spatial characteristics (3), to confusion of semantic cat egories (4) at the highest level of this hierarchy of complexity in processing. The Bender-Gestalt test (see pp. 385-393), particularly cards 1, 2, and 6. and the Benton Visual Retention test (see pp. 447-451) tend to bring out perseverative ten dencies, as do tasks involving writing to command or copying letters, numbers, or words, Perseverative patients often have difficulty in just writing the alphalx`1. a mini* 521