Evidence for an attraction account of closing-in behaviour

Closing-In Behavior and Motor Distractibility in Persons with Brain Injury

OBJECTIVE

This study investigates closing-in behavior (CIB), a phenomenon observed in graphic copying tasks when responses encroach upon or overlap the model. The behavior is most common amongst individuals with dementia and amongst pre-school children. We explored the relationship between CIB and the 'distractor effect' in reaching, whereby salient visual stimuli can influence the spatial trajectory of the reach.

METHOD

A group of individuals with overlap-CIB (n = 9), without CIB (n = 9) and healthy controls (HC; n = 6) underwent a task-irrelevant and a task-relevant distractors and the deviation of the movement trajectory towards the distractor location was measured in both tasks.

RESULTS

Individuals with graphic CIB showed more distractor-directed veering during reaching than did individuals without CIB or HC, provided that the distractor was relevant for the reaching task.

CONCLUSIONS

These results strengthen the relationship between CIB and the distractor effect and reinforce the hypothesis that CIB represents a disinhibited tendency to act towards the focus of attention.

Closing-in Phenomenon in Huntington's Disease: A Neuropsychological Marker of Frontal/Executive Dysfunction

Objective

In visuo-constructional tasks, patients may reproduce drawings near-to or superimposed on a model, showing the so-called "Closing-in" (CI), often ascribed to a defect in inhibitory control. CI has been described in neurological conditions, but no studies have explored CI in Huntington's disease (HD), a neurodegenerative disorder often involving the frontal cortical-subcortical circuits. We searched for the occurrence of CI in HD patients and systematically investigated its correlates to find a clinical marker of the frontal/executive dysfunctions in the early examination of HD patients.

Method

We assessed 130 HD participants, who performed a graphic coping task and a neuropsychological, psychiatric, motor, and functional assessment.

Results

CI occurred in 52/130 (40%) HD patients, with 43/52 (82.7%) superimposing their copy directly on the model. MANOVA showed that HD patients with CI scored significantly poorer on Symbol digit modality test, Stroop-color word - reading test, Stroop-color word - interference test, Trail making test - part B, and Phonological verbal fluency test. However, a logistic regression analysis revealed that the significant predictor of the occurrence of CI was the score on Stroop-color word - interference test.

Conclusions

HD patients may show CI in graphic tasks, and it could be related to a defect in inhibitory control impeding the switch of attention from the model to the copying space, and releasing a default tendency which causes an attraction of hand movement towards the focus of visual attention. CI might be a useful clinical marker for the early detection of frontal/executive defects in HD patients.

Closing-in Behavior and Parietal Lobe Deficits: Three Single Cases Exhibiting Different Manifestations of the Same Behavior

Closing-in behavior (CIB) is observed in copying tasks (graphic or gestural) when the copy is performed near or on the top of the model. This symptom has been classically considered to be a manifestation of constructional apraxia and is often associated with a visuospatial impairment. More recent work emphasizes the attentional and/or executive nature of the behavior and its association with frontal lobe dysfunction. We describe three patients in whom CIB was associated with posterior parietal deficits of different etiologies (stroke in Patient 1 and dementia in Patients 2 and 3). In copying figures, Patient 1 produced the shape with high accuracy but the rendering overlapped the model, while for Patients 2 and 3 the copies were distorted but overlapping or in close proximity to the target. In gesture imitation, Patient 2 performed the gestures toward the examiner's space, while Patient 1 showed a peculiar form of CIB: when he was asked to place the ipsilesional arm in a position that mirrored the contralesional hand, Patient 1 moved his hand toward his contralesional hand. Patient 3 did not present gestural CIB. While CIB in Patient 1 was associated with selective deficits in executive functions and attention, additional visuospatial deficits were observed in Patients 2 and 3. The latter two patients showed a general visuoconstructional deficit. These case studies support a primary attentional account of CIB but also suggest that visuoconstructional impairments may contribute to the emergence of CIB, in some subjects. This evidence argues for different types of CIB with different cognitive and neural underpinnings. Furthermore, the data support the hypothesis of a differential involvement of fronto-parietal network in CIB.

The Closing-In Phenomenon in an Ecological Walking Task

OBJECTIVES

Alzheimer's disease (AD) patients may show the Closing-in (CI), a tendency to reproduce figures close to or superimposed on the model. AD patients with CI might manifest reduced functional independence compared to AD patients without CI, but no study directly assessed if CI can hamper common daily living activities. To address this issue here we investigated whether AD patients with CI veer their walking trajectory toward irrelevant objects more often than AD patients without CI.

METHODS

Fifty AD individuals, and 20 age- and education-matched healthy adults, underwent a graphic copying task to detect CI and a newly developed walking task to assess the tendency to veer toward irrelevant objects and to bump into them. All participants also completed a comprehensive neuropsychological battery to assess dementia severity; impairments in frontal/executive, visuo-spatial, visuo-constructional, and memory domains; and functional independence in daily living activities.

RESULTS

Graphic CI occurred in 34/50 (68%) AD patients (AD-CI group) who achieved significantly lower scores on frontal/executive abilities, and daily living functioning than AD individuals not showing CI. Most AD-CI patients (20/34; 58.8%) also showed at least one veering error in the walking task. Participants with CI and veering errors showed significantly poorer performance on Stroop test, and lower level of functional independence than AD individuals with CI in isolation.

CONCLUSIONS

CI on graphic tasks can identify difficulties in walking and in complying with everyday activities in AD patients. These observations demonstrate the value of assessing CI in copying tasks. (JINS, 2018, 24, 437-444).

Thinking inside the box: Spatial frames of reference for drawing in Williams syndrome and typical development

BACKGROUND

Successfully completing a drawing relies on the ability to accurately impose and manipulate spatial frames of reference for the object that is being drawn and for the drawing space. Typically developing (TD) children use cues such as the page boundary as a frame of reference to guide the orientation of drawn lines. Individuals with Williams syndrome (WS) typically produce incohesive drawings; this is proposed to reflect a local processing bias.

AIMS

Across two studies, we provide the first investigation of the effect of using a frame of reference when drawing simple lines and shapes in WS and TD groups (matched for non-verbal ability).

METHODS AND PROCEDURES

Individuals with WS (N=17 Experiment 1; N=18 Experiment 2) and TD children matched by non-verbal ability drew single lines (Experiment One) and whole shapes (Experiment Two) within a neutral, incongruent or congruent frame. The angular deviation of the drawn line/shape, relative to the model line/shape, was measured.

OUTCOMES AND RESULTS

Both groups were sensitive to spatial frames of reference when drawing single lines and whole shapes, imposed by a frame around the drawing space.

CONCLUSIONS AND IMPLICATIONS

A local processing bias in WS cannot explain poor drawing performance in WS.

Planning ability impairments in probable Alzheimer's disease patients: Evidence from the Tower of London test

Alzheimer's disease (AD) is associated with progressive impairment of higher-level cognitive abilities. Previous research suggests that early impairment of executive functions occurs during the course of the disease, but few studies have specifically investigated planning ability in an AD population.

Drawing Disorders in Alzheimer's Disease and Other Forms of Dementia

Drawing is a multicomponential process that can be impaired by many kinds of brain lesions. Drawing disorders are very common in Alzheimer's disease and other forms of dementia, and can provide clinical information for the distinction of the different dementing diseases. In our review we started from an overview of the neural and cognitive bases of drawing, and from a recollection of the drawing tasks more frequently used for assessing individuals with dementia. Then, we analyzed drawing disorders in dementia, paying special attention to those observed in Alzheimer's disease, from the prodromal stages of the amnesic mild cognitive impairment to the stages of full-blown dementia, both in the sporadic forms with late onset in the entorhino-hippocampal structures and in those with early onset in the posterior neocortical structures. We reviewed the drawing features that could differentiate Alzheimer's disease from vascular dementia and from the most frequent forms of degenerative dementia, namely frontotemporal dementia and Lewy body disease. Finally, we examined some peculiar aspects of drawing disorders in dementia, such as perseverations, rotations, and closing-in. We argue that a careful analysis of drawing errors helps to differentiate the different forms of dementia more than overall accuracy in drawing.

Frontal-executive constructional apraxia: when delayed recall is better than copying

In assessments of visuospatial function and memory, patients are often required to copy a figure and later to reproduce that figure from memory. Whereas most people perform better on a copying task than when drawing from memory, in this study we describe an unusual pattern of performance in which patients are better at drawing from memory than copying. Consecutive patients in a neurocognitive disorders clinic were given a battery of clinical cognitive tests that included copying a figure of intersecting pentagons and then drawing the figure from memory. Patterns of drawing performance at the two time points were compared to the profile of other cognitive deficits.

RESULTS

A subgroup of four patients with frontal dysfunction showed marked improvement in drawings at a delay compared to copying. Prior studies have indicated that most patients have declines in drawing performance at a delay. The unusual pattern of better performance at a delay compared to an initial copy occurred in patients with frontal dysfunction. These patients' visuoconstructive deficit and subsequent improvement could be related to either a failure to disengage when a model is present, to memory consolidation with increased reliance on top-down processing in the delay condition, or to relative preservation of global versus local aspects of a stimulus in memory. The addition of a task to assess drawing after a delay to a standard clinical screening battery such as the Mini-Mental Status Examination (MMSE) provides the opportunity to evaluate this phenomenon that may be indicative of frontal-executive dysfunction.

Frontal defects contribute to the genesis of closing-in in Alzheimer's disease patients

Closing-in (CI) refers to copying drawings near to or superimposed on the original model, and is often observed in Alzheimer's disease (AD) patients. Contrasting hypotheses have been suggested to explain CI, but no prospective study has directly verified these interpretations. We evaluated the role of frontal/executive versus visuo-spatial impairments in a prospective sample of AD patients, and also explored whether different types of CI are related to specific neuropsychological tasks. We enrolled 64 AD patients who underwent copying tasks and an extensive neuropsychological assessment of visuo-spatial and visuo-constructional skills, frontal/executive abilities and anterograde memory. AD patients with CI showed more severe impairment on frontal/executive functions than AD patients without CI. Moreover, the tendency to produce copies superimposed on the model was selectively associated with poor inhibitory control for irrelevant responses. On this basis, we suggest that different CI phenomena could be ascribed to distinctive frontal/executive defects.

Inducing closing-in phenomenon in healthy young adults: the effect of dual task and stimulus complexity on drawing performance

Closing-in (CI) is the tendency to act very close to the model in tasks such as drawing, 3D construction, gesture imitation, or writing. Closing-in is observed in degenerative and focal brain diseases, but also in normally developing children. In the present paper, three experiments were conducted to evaluate whether CI can be triggered during a copying task in normal young adults by increasing stimulus complexity and attentional load. Participants were required to copy complex lines in one of three conditions: without interfering activities (baseline), during counting, or during execution of a 2-back short-term memory task. In Experiment 1, participants were required to reproduce horizontally aligned stimuli, starting from a dot placed below each stimulus and proceeding from left to right; in Experiment 2, stimuli were again horizontally aligned, but the starting dot was placed above each stimulus, and writing proceeded from right to left; in Experiment 3, stimuli were aligned vertically and copying proceeded in upward direction. Results from all experiments showed that when normal young adults are engaged in an attentional-demanding concurrent activity, they tend to approach to the model, whereas the effect of stimulus complexity disappeared with unusual writing direction (Experiments 2 and 3). These findings demonstrate that even in normal young adults, a reduction in available attentional resources can release an attraction toward the model.

Closing-in behavior in mild cognitive impairment: an executive deficit

This study explored Closing-in behavior (CIB), the tendency in figure copying to draw very close to or on top of the model, in mild cognitive impairment (MCI). The files of 154 people diagnosed with MCI were reviewed and CIB was identified in 21% of cases. Two approaches were used to explore CIB. First, we capitalized on the diverse cognitive profiles within MCI, subdividing the overall sample into people with and without memory deficits. The frequency of CIB was significantly higher in multidomain non-amnestic MCI than in multidomain amnestic MCI, suggesting that CIB is not associated with specific memory impairment. Second, we assessed the cognitive correlates of CIB, by selecting patients with MCI who completed a battery of executive, visuo-constructional and memory tasks. Sub-groups of patients with and without CIB showed a similar overall severity of cognitive decline and comparable performance in visuo-constructional and memory tasks, but those with CIB were slightly but significantly more impaired on executive function tasks. The study provides evidence against memory-based accounts of CIB, and supports recent suggestions that executive impairments are the dominant cognitive correlate of this clinical sign.

A large-scale retrospective study of closing-in behavior in Alzheimer's disease

The frequency and characteristics of closing-in behavior (CIB) were examined in 797 patients with Alzheimer's disease (AD), 132 of whom were followed up longitudinally. The frequency of CIB increased with the complexity of the graphic copying task and with the severity of Alzheimer's disease. Regression analyses suggested that attentional deficits are critical factors for the appearance of CIB, but that visuospatial impairments also play an important role in the emergence of severe forms of CIB.

Closing-in behaviour in preschool children

Many pre-school children show closing-in behaviour (CIB) in graphic copying tasks: a tendency to place their copy abnormally close to or even on top of the model. Similar phenomena have been studied in patients with dementia, though it is unclear whether the superficial similarities between CIB in development and dementia reflect common underlying cognitive mechanisms. The aim of the present study was to investigate the cognitive functions involved in CIB in pre-school children. Forty-one children (3-5 years) were assessed for CIB, and completed a neuropsychological battery targeting visuospatial abilities, short term memory (verbal and spatial) and attention (sustained attention, selective attention and attention switching). Binary logistic regression found that performance on the attention subtests was the best unique predictor of CIB. A second analysis, in which the three attention subtests were entered as separate predictors, suggested that attention switching ability was most strongly related to CIB. These results support the view that CIB in children reflects inadequate attentional control. The convergence of these results with similar observations in patients with dementia further suggests that similar cognitive factors underlie CIB in these two populations.

The role of the posterior parietal cortex in drawing by copying

Impaired ability to draw visually presented figures by copying represents one major manifestation of constructional apraxia (CA). Previous clinical studies have indicated that CA is caused by lesions in the posterior parietal cortex (PPC), but the functional roles of the PPC remain unclear. A spared ability to trace with an impaired ability to copy indicates that deficits lie not in low-level visuomotor processing, but rather in a coordinate transformation involving production of an egocentric representation of model trajectory in the drawing space, which is spatially separated from the model space. To test the hypothesis that the PPC plays a role in coordinate transformation, we compared brain activities for drawing by copying and tracing using functional magnetic resonance imaging (fMRI). Healthy participants traced over the visually presented model or copied the model on a separate space. To avoid potential confounders of differences in behavioral performances as well as eye movements, a memory-guided condition was introduced, resulting in four drawing conditions; tracing over or copying a model at different locations (tracing and copying), with or without an on-screen model (visual and memory guidance). As hypothesized, the intraparietal sulcus (IPS) bilaterally in the PPC showed significantly greater activations in copying than in tracing, under both visual and memory guidance, with a distinct activation pattern involving the premotor and mesial motor regions. This study indicates a role of the PPC in coordinate transformation for drawing by copying, which may be important for the copying deficit observed in CA.