Evaluating Unilateral Spatial Neglect Post Stroke: Working Your Way Through the Maze of Assessment Choices

This study identified, using a comprehensive review of the literature, 62 standardized and nonstandardized assessment tools that exist to evaluate unilateral spatial neglect (USN). Each standardized tool was critically appraised according to its purpose (hemispace assessed), psychometric properties, and client appropriateness. The findings on the 28 standardized tools were compiled into a USN Assessment Summary Guide to facilitate clinical decision-making regarding the standardized USN assessments that are appropriate for specific clients at different phases of their recovery post stroke.

Flashbacks and HPPD: A Clinical-oriented Concise Review

A unique characteristic of LSD, LSD-like and substances with hallucinogenic properties is the recurrence of some or all the hallucinogenic symptoms which had appeared during the intoxication after the immediate effects of the substance had worn off. This recurring syndrome, mainly visual, is not clearly understood. The terms Flashback and Hallucinogen Persisting Perception Disorder (HPPD) have been used interchangeably in the professional literature. We have observed at least two different recurrent syndromes, the first Flashback Type we refer to as HPPD I, a generally short-term, non-distressing, benign and reversible state accompanied by a pleasant affect. In contrast, the second HPPD Type we refer to as HPPD II, a generally long-term, distressing, pervasive, either slowly reversible or irreversible, non-benign state accompanied by an unpleasant affect. HPPD I and II appear to be part of a broad spectrum of non-psychopathological and psychopathological states reported by hallucinogen users. HPPD I and II may be clinically characterized by prodromal symptoms, onset, content of visual imagery, precipitators, frequency, duration and intensity of perceptual recurrences, severity, course, differential diagnosis, accompanying mood and affect, insight and remission. Pharmacological therapy with or without preceding or following co-occurring psychiatric disorders have been shown to ameliorate this syndrome. A large variety of medications may be utilized to alleviate this condition, but with differential results suggesting several subtypes. The purpose of this manuscript is to provide a clinical-oriented, comprehensive and concise review to treating psychiatrists.

[Olfactory disorders]

In contrast to what the medical community thought, human olfaction is far more functional and performing than previously believed. Almost fifteen percent of the general population is concerned by an olfactory disorder. The causes of olfactory dysfunction are numerous and in certain cases olfactory alteration precedes neurodegenerative or systemic diseases. Thus, a thorough workup consisting of an otolaryngological examination, olfactory testing and if necessary further exams is emphasized. Since medical knowledge on olfactory dysfunction is only emerging, curative treatments are not always available. In contrast to other neurons, olfactory neurons have the capacity of spontaneous regeneration and a large part of the physician's job is to inform and follow-up patients with olfactory disorders.

Ordinal Linguistic Personification as a Variant of Synesthesia

This study examines the principles underlying ordinal linguistic personification (OLP): the involuntary and automatic tendency in certain individuals to attribute animate-like qualities such as personality and gender to sequential linguistic units (e.g., letters, numerals, days, months). This article aims to provide four types of evidence that OLP constitutes a form of synesthesia and is likely to have the same neurodevelopmental basis. We show that (a) OLP significantly co-occurs with other variants of synesthesia, (b) OLP associations (like those of synesthesia) are highly consistent over time (Experiment 1), (c) OLP associations (like those of synesthesia) have the characteristic of letter-to-word transference (i.e., they spread from initial letters throughout words) (Experiment 2), and (d) OLP associations (like those of synesthesia) are automatically generated and interfere in Stroop-type tasks (Experiment 3). We argue that these shared characteristics suggest a unified underlying behavior, and propose OLP as a subtype of synesthesia. In so doing, our study extends the range of reported phenomena that are known to be susceptible to cross-modal association.

Characterisation of unilateral neglect by physiotherapists

PURPOSE

It is not known how clinicians characterise unilateral neglect (ULN) or whether they consider the different types of ULN during their evaluation and management of patients with this condition. The purpose of this study was to gain insight into physiotherapists' understanding of ULN and to identify the terminology used by clinicians to characterise neglect behaviour.

METHOD

Qualitative research design employing focus groups and one-to-one interviews. Thirty-three experienced neurological and novice physiotherapists from one Australian state were asked to discuss how they characterise ULN and to explain what they meant by the terms they used. Data analysis involved preparation of verbatim transcripts followed by coding, data reduction, and identification of major themes. Data management was facilitated using NVivo computer software.

FINDINGS

Terms such as sensory neglect, visual neglect, extinction, inattention, and functional neglect were used to characterise neglect behaviour but there was considerable confusion between many of these terms. Motor neglect was an unfamiliar concept to many participants. Functional implications of ULN were considered important. Characterisations of neglect according to the spatial distribution of the behaviour were uncommon.

CONCLUSIONS

Despite awareness of many types of neglect, the physiotherapists in this study did not have a clear understanding of how to accurately characterise the different types of ULN. Education to address the issue is required.

Disturbed line bisection is associated with posterior brain lesions

Neglect patients classically fail to orient and respond to stimuli appearing on their contralesional side. Traditionally, the neglect syndrome has been associated with damage to the right inferior parietal lobule (IPL) and the right temporo-parietal junction (TPJ). Neglect is popularly assessed by two different tasks: line bisection and cancellation. In a previous study (S. Ferber, H.-O. Karnath, How to assess spatial neglect-line bisection or cancellation tasks. J. Clin. Exp. Neuropsychol. 23 (2001) 599-607), we observed that performance on the cancellation task correlates well with the characteristic behavioral disorders used to clinically diagnose spatial neglect, while line bisection was a poor predictor. This might indicate that the disability to correctly bisect lines is a distinct disorder separable from spatial neglect. Here, we assess the anatomy of the patients investigated in that study, and reveal that damage to the temporo-occipital junction correlates with poor performance in the line bisection task. This work extends previous work by Binder et al. (J. Binder, R. Marshall, R. Lazar, J. Benjamin, J.P. Mohr, Distinct syndromes of hemineglect. Arch. Neurol. 49 (1992) 1187-1194) suggesting that line bisection and cancellation identify distinct syndromes. The data suggest that these two tasks dissociate both in terms of behavior and anatomy. This anatomical distinction may help reconcile our recent finding that spatial neglect is associated with damage to the superior temporal cortex and insula, while others have identified the IPL and TPJ. Specifically, we note that our previous anatomical studies did not use the line bisection task to select neglect patients, while many others used this task. We suggest that anatomical studies that combine patients from both of these two distinct groups may result in misleading findings.

[Visuoperceptual processing in Parkinson's disease: from the retina to the frontal cortex]

INTRODUCTION

The growing interest in the cognitive impairment shown by patients with Parkinson's disease has led to a wealth of research in this line over recent years. In this paper we review the visuospatial alterations in these patients, which are usually linked to other disorders such as those affecting planning, sequencing, attention or mnemonic processes.

DEVELOPMENT

We report the most relevant findings, which suggest that the existence of these visuospatial disorders shown by patients with Parkinson's disease are not always secondary to other frontal-type cognitive impairments, as has been claimed in recent years. Instead, they may be due to disorders in other anterior points of the perceptive process (as a result of dopaminergic deficits in basal-thalamic-cortical circuits). Thus, visuoperceptual disorders are classified according to their location in the brain: from the retina to the lateral geniculate nucleus, the visual cortex and the extrastriate cortex and, finally, the frontal and prefrontal cortex.

CONCLUSIONS

We propose this classification of the disorders according to their location to aid in achieving an objective selection of the sample and of the neuropsychological tests used in studies. In this regard, we consider that there should be a higher degree of agreement among researchers when it comes to designing research projects that deal with visuospatial disorders in patients with Parkinson's disease.

Anatomy of spatial attention: insights from perfusion imaging and hemispatial neglect in acute stroke

The site of lesion responsible for left hemispatial neglect after stroke has been intensely debated recently. Some studies provide evidence that right angular lesions are most likely to cause left neglect, whereas others indicate that right superior temporal lesions are most likely to cause neglect. We examine two potential accounts of the conflicting results: (1) neglect could result from cortical dysfunction beyond the structural lesion in some studies; and (2) different forms of neglect with separate neural correlates have been included in different proportions in separate studies. To evaluate these proposals, we studied 50 patients with acute right subcortical infarcts using tests of hemispatial neglect and magnetic resonance diffusion-weighted and perfusion-weighted imaging performed within 48 h of onset of symptoms. Left "allocentric" neglect (errors on the left sides of individual stimuli, regardless of location with respect to the viewer) was most strongly associated with hypoperfusion of right superior temporal gyrus (Fisher's exact test; p < 0.0001), whereas left "egocentric" neglect (errors on the left of the viewer) was most strongly associated with hypoperfusion of the right angular gyrus (p < 0.0001). Patients without cortical hypoperfusion showed no hemispatial neglect. Because the patients did not have cortical infarcts, our data show that neglect can be caused by hypoperfused dysfunctional tissue not detectable by structural magnetic resonance imaging. Moreover, different forms of neglect were associated with different sites of cortical hypoperfusion. Results help explain conflicting results in the literature and contribute to the understanding of spatial attention and representation in the human brain.

A revised method for analysing neglect using the landmark task

In order to better disentangle 'perceptual' and 'response' biases in neglect patients, Bisiach and his co-workers developed a new version of the 'landmark task'. In their version, subjects are required to choose which is the longer (first condition) or the shorter (second condition) of the two portions of a pre-bisected horizontal line. Two indices were proposed, for the purpose of measuring perceptual and response bias respectively. The perceptual bias index (PB) is the constant error across conditions, while the response bias index (RB) is the degree of response consistency between conditions. Although valuable in a clinical context, these indices are not mathematically independent of one another. Furthermore, they do not exploit all of the information available in a given set of landmark data, since the responses made at the different landmark locations are all averaged together. To overcome these problems, we propose two new indices that can be derived from the revised landmark task. Our perceptual bias index is the Point of Subjective Equality (PSE)--the mean landmark location that appears to be halfway along the line. The response bias index, M, is the mean probability of making a response that opposes the patient's subjective midpoint. PSE and M are mathematically independent of each other and use most of the landmark information. The method and its theoretical foundation are summarized, and illustrative data obtained from brain damaged patients and control subjects are presented. Finally, computational procedures are provided for both PSE and M.

Not all synaesthetes are created equal: Projector versus associator synaesthetes

In synaesthesia, ordinary stimuli elicit extraordinary experiences. When grapheme-color synaesthetes view black text, each grapheme elicits a photism-a highly specific experience of color. Importantly, some synaesthetes (projectors) report experiencing their photisms in external space, whereas other synaesthetes (associators) report experiencing their photisms "in the mind's eye." We showed that projectors and associators can be differentiated not only by their subjective reports, but also by their performance on Stroop tasks. Digits were presented in colors that were either congruent or incongruent with the synaesthetes' photisms. The synaesthetes named either the video colors of the digits or the colors of the photisms elicited by the digits. The results revealed systematic differences in the patterns of Stroop interference between projectors and associators. Converging evidence from first-person reports and third-person objective measures of Stroop interference establish the projector/ associator distinction as an important individual difference in grapheme-color synaesthesia.

Perceptual and premotor neglect: is there an ideal task to categorise patients?

This review focuses on Edoardo Bisiach's particular input into the perceptual/premotor taxonomy within the neglect syndrome and assesses arguments and experimental designs that have been presented both for and against the dichotomy. Bisiach made most crucial contributions to this topic as well as increasing insights into the syndrome of hemispatial neglect more generally. Most importantly, he elucidated its relevance to visual neuropsychological and neuroscientific research.

Assessments and nursing care for right brain-damaged stroke patients: Focusing on neglect and related symptoms

The purpose of present study was to identify the behavioural characteristics and examine assessments of nursing care among right brain-damaged stroke patients with neglect within 1 year following initial onset. Characteristics related to higher cerebral dysfunction were extracted and patient grouping was attempted through cognition (Mini-Mental State Examination) and physical function (Barthel Index) plots. The characteristics and implications for nursing care for each group were analyzed. Twelve patients were classified into four groups using cognitive-physical function evaluations together with subjective and objective data associated with neglect. 'Neglect' has been regarded as a disorder of spatial perception. However, the characteristics observed in Group 2 suggest that 'neglect' may have another facet, manifesting as disorders in perceiving continuous spatio-temporal changes of an action and comprehending the context of a situation. In these patients, although 'by calling attention' is the conventional care, more appropriate care should be provided based on an assessment of cognitive-physical function and spatio-temporal recognition of an action.

[Perceptive and praxic impairments in traumatic brain injury patients: significance in activities of daily living]

OBJECTIVE

The main goal of the present study is to describe the implication of different perceptive and praxic deficits in activities of daily living (ADL). We also review some assessing scales and intervention techniques used in the training of these mentioned alterations after a traumatic brain injury (TBI).

DEVELOPMENT

There are three kinds of processes important for a correct ideation, motor planification and execution of a learned purposeful movement (praxis). Some of these processes are related to the visual basic perception of the objects (colour, form, size, etc). Others are related to the most complex perception functions (depth, location, recognition,etc). The third group of functions are those integrating the sensory information (discrimination right left side, corporal scheme disorders, etc). If ADL performance needs a suitable functioning of different structures of the nervous central system, then assessment and treatment will be necessary to obtain the best independence level of TBI patients. This is the main objective in Occupational Therapy. ADL may be separated in two different groups: basic abilities (feeding, grooming, dressing, etc) and instrumental abilities (meal preparation, managing money, shopping, using public transportation, etc).

CONCLUSION

Impairments in both praxic and perceptive processes constitute one of the most prevalent deficits in TBI patients. From a clinical point of view, these deficits may lack the capacity to carry an independent life.

Hemispatial neglect: Subtypes, neuroanatomy, and disability

OBJECTIVE

To assess the relative frequency of occurrence of motor, perceptual, peripersonal, and personal neglect subtypes, the association of neglect and other related deficits (e.g., deficient nonlateralized attention, anosognosia), and the neuroanatomic substrates of neglect in patients with right hemisphere stroke in rehabilitation settings.

METHODS

The authors assessed 166 rehabilitation inpatients and outpatients with right hemisphere stroke with measures of neglect and neglect subtypes, attention, motor and sensory function, functional disability, and family burden. Detailed lesion analyses were also performed.

RESULTS

Neglect was present in 48% of right hemisphere stroke patients. Patients with neglect had more motor impairment, sensory dysfunction, visual extinction, basic (nonlateralized) attention deficit, and anosognosia than did patients without neglect. Personal neglect occurred in 1% and peripersonal neglect in 27%, motor neglect in 17%, and perceptual neglect in 21%. Neglect severity predicted scores on the Functional Independence Measure and Family Burden Questionnaire more accurately than did number of lesioned regions.

CONCLUSIONS

The neglect syndrome per se, rather than overall stroke severity, predicts poor outcome in right hemisphere stroke. Dissociations between tasks assessing neglect subtypes support the existence of these subtypes. Finally, neglect results from lesions at various loci within a distributed system mediating several aspects of attention and spatiomotor performance.

Comparison of the Milner and Bisiach Landmark Tasks: can Neglect Patients be Classified Consistently?

The aim of the presented studies was to investigate whether classifications of neglect patients into perceptual (i.e. identifying a patient as suffering from mainly attentional/space representation deficits) and premotor (judging the main impairment to be related towards actions into contralesional space) categories are consistent across similar Landmark techniques that have, in the past, been designed to tease these potentially overlapping aspects of hemispatial neglect apart. Thirteen patients with hemispatial neglect were tested both with the Landmark Test, adapted from Milner et al. (1992; 1993) in which they had to manually point to the half of a centrally pre-bisected line that, to them, appeared shorter and the motor version of the Bisiach Landmark Test (Bisiach et al., 1998) in which, rather than just judging a centrally prebisected line, they had to judge asymmetrically bisected lines as well. The specific question was whether these two tasks, which are very similar, would categorise the same set of patients in the same way. Most patients could be classified into either the premotor or perceptual category in each task, but no consistent categorisation emerged across the two tests. Just three out of the thirteen patients were consistently classified across both tests. Despite the apparent similarity of the two tests the Milner Landmark Test proved to be much more sensitive to identifying even a slight perceptual bias and seems therefore the test of choice if identification of perceptual bias is the major interest.

Caloric stimulation in neglect: evaluation of response as a function of neglect type

Contralesional neglect may be induced by either unawareness of contralesional stimuli (attentional neglect, AN) or failure to act in contralesional space (intentional neglect, IN). We examined whether contralesional cold caloric stimulation differentially affects AN versus IN. Patients with left-sided neglect (n = 16) from right-hemisphere lesions performed target cancellation and line bisection tasks. Using a video-based apparatus that reverses the right and left side of stimuli, patients with abnormal cancellation performance were divided into those with AN and those with IN. The 5 subjects with normal cancellation performance but rightward bisection bias were also separated into 2 neglect groups. Subjects performed cancellation or bisection tasks before and immediately after irrigation of the left auditory canal with ice water. Caloric stimulation induced brisk rightward nystagmus in all subjects. Subjects with AN cancelled more left-sided targets after stimulation than those with IN (p = .02). Whereas caloric stimulation significantly shifted bisection error leftward for both IN and AN groups (p < .0001), AN patients exhibited a greater magnitude of shift than the IN patients. While the basis for differential performance remains undefined, the data indicate that caloric stimulation influences AN more than IN.

Amusia and musicogenic epilepsy

Amusia and musicogenic epilepsy are clinical disorders that provide a window into the localization of music in the brain. Classic clinical studies of patients with these disorders, coupled with more recent studies employing modern neuroimaging and sophisticated neuropsychologic paradigms, have converged in helping to elucidate the complex neural systems that are utilized in decoding music. The notion of cerebral dominance for music has been replaced by a concept of modular but interconnected networks that have wide bilateral localization in the brain and that are molded both by genetics and experience. These disorders also provide insight into the important interface between music and emotion.

Categorisation of 'perceptual' and 'premotor' neglect patients across different tasks: is there strong evidence for a dichotomy?

The aim of the presented studies was to investigate whether classifications of neglect patients into perceptual (i.e. identifying a patient as suffering from mainly attentional/space representation deficits) and premotor (judging the main impairment to be related towards actions into contralesional space) categories is consistent across different line bisection assessment techniques that have, in the past, been designed to tease these potentially overlapping aspects of hemispatial neglect apart. Twelve patients with hemispatial neglect and three control groups were tested with the Overhead Task, adapted from Nico [Neuropsychologia 34 (1996) 471] in which patients were asked to bisect lines that were mirror reversed, the Pulley Device Technique, adapted from Bisiach et al. [Neurology 40 (1990) 1278] in which they had to perform a movement opposite to the direction of the transaction mark that bisected the line and the Landmark Test, adapted from Milner et al. [Neuropsychologia 30 (1992) 515] in which they had to manually point to the half of a centrally pre-bisected line that, to them, appeared shorter. The specific question was whether these three tasks would categorise the same set of patients in the same way?Most patients could be classified into either the premotor or perceptual category in each task, but no consistent categorisation emerged across the three techniques. Just 1 out of the 12 patients, was consistently classified across all three tasks. It seemed that despite the fact that all tasks essentially required a line bisection response, the perceptual and motor differences between the tasks were still great enough to result in inconsistent classifications. The Landmark Task classified the majority of patients into the perceptual neglect category, while the Overhead and Pulley Device Techniques tended to identify more patients as suffering from a premotor deficit (albeit not the same set of patients).

Comparing tests of tactile sensibility: aspects relevant to testing children with spastic hemiplegia

Children with hemiplegic cerebral palsy (OP) commonly exhibit tactile sensory deficiencies in their hands in addition to their motor problems. The aim of this study was to compare and evaluate the usefulness of some common tests of tactile sensibility for use with children with hemiplegic CP. Twenty-five children with hemiplegia aged between 5 and 18 years, and 19 control individuals participated. All children were examined with Semmes-Weinstein monofilaments, two-point discrimination (2PD), stereognosis of familiar objects, stereognosis of forms, and functional sensibility. Dexterity, spasticity, and bimanual task performance were also assessed. Results from the different sensory tests deviated greatly. We found three tests to be useful: 2PD of 3 mm spacing, which was the most sensitive test, stereognosis of familiar objects, and functional sensibility assessed through the Pick-up test (comparing performance with and without the influence of vision). Stereognosis of forms and threshold values of touch (Semmes-Weinstein monofilaments) are seemingly less useful tests for children with CNS impairments. Deficient sensibility was strongly related to dexterity. Aspects concerning the testing methodology are discussed.

Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series

OBJECTIVE

To evaluate the efficacy of carbidopa L-dopa (Sinemet) in reducing left spatial neglect after stroke.

DESIGN

Case series.

SETTING

Inpatient neurorehabilitation unit in a regional rehabilitation center.

PARTICIPANTS

A convenience sample of 4 women with right brain strokes and left neglect.

INTERVENTION

A trial of carbidopa L-dopa to treat left neglect, if indicated by selected subtests of the Behavioral Inattention Test (BIT).

MAIN OUTCOME MEASURES

Baseline and posttreatment evaluation with the modified BIT and the FIM instrument.

RESULTS

Three of 4 subjects had significant improvements in their modified BIT scores (8%, 12%, 27%, respectively) and their functional status on the FIM.

CONCLUSION

With further study, carbidopa L-dopa may be shown to reduce unilateral spatial neglect and thereby improve rehabilitation outcomes.

Two types of auditory neglect

Auditory neglect, defined as inattention to stimuli within the left hemispace, is mostly reported in association with left ear extinction in dichotic listening. However, it remains disputed as to how far dichotic extinction reflects a primary attentional deficit and is thus appropriate for the diagnosis of auditory neglect. We report here on four patients who presented left ear extinction in dichotic listening following right unilateral hemispheric lesions. Auditory spatial attention was assessed with two additional tasks: (i) diotic test by means of interaural time differences (ITDs), simulating bilateral simultaneous spatial presentation of the dichotic tasks without the inconvenience of interaural intensity or content difference; and (ii) sound localization. A hemispatial asymmetry on the ITD diotic test or a spatial bias on sound localization were found to be part of auditory neglect. Two patients (J.C.N. and M.B.) presented a marked hemispatial asymmetry favouring the ipsilesional hemispace in the ITD diotic test, but did not show any spatial bias in sound localization. Two other patients (A.J. and E.S.) had the reverse profile: no hemispatial asymmetry in the ITD diotic test, but a severe spatial bias directed to the ipsilesional side in sound localization. J.C.N. and M.B. had mainly subcortical lesions affecting the basal ganglia. A.J. and E.S. had cortical lesions in the prefrontal, superior temporal and inferior parietal areas. Thus, there are two behaviourally and anatomically distinct types of auditory neglect characterized by: (i) deficit in allocation of auditory spatial attention following lesions centred on basal ganglia; or (ii) distortion of auditory spatial representation following frontotemporoparietal lesions.

Pseudohallucinations: a pseudoconcept? A review of the validity of the concept, related to associate symptomatology

"Pseudohallucination" is a concept used in the classification of nonpsychotic perceptual disorders. This report describes the history of the concept and investigates whether pseudohallucinations can be differentiated from related psychopathological symptoms, such as hallucinations, re-experiencing, and dissociative phenomena. We performed a literature review, which shows that pseudohallucinations and related symptoms have low construct validity and are, accordingly, clinically ambiguous. Most likely, pseudohallucinations are placed on an overlapping continuum of symptomatology that includes perceptual disorders, re-experiencing, (dissociative) imagery, and normal thought and memory processes. Recommendations are made regarding the specification of dimensions of this continuum. The term "nonpsychotic hallucinations" is preferred over "pseudohallucination."

Hypersensitivity to sound--questionnaire data, audiometry and classification

This study included consecutive case histories and audiometry of 100 patients with hypersensitivity to sounds. There are several different conditions with the symptom of hypersensitivity to sounds. Hyperacusis is one of those and is seldom described in the literature. The term hyperacusis is often used synonymously with hypersensitivity to sound. We propose that there is a specific condition that could be termed hyperacusis. Hyperacusis is often elicited by loud sounds or by a number of other traumata or diseases. It is not typical of occupational noise exposure (with the exception of exposure to music). The typical patient is relatively young, the mean age being approximately 10 years less than for a population of patients with tinnitus or noise-induced hearing loss. In addition to hypersensitivity to sound, the patients often suffer from tinnitus (86%). Sounds are frequently painful and exposure to loud sounds worsens the condition for some time. The patients often have headaches. Pure tone audiograms show normal hearing or a slight high tone loss. The uncomfortable loudness level is markedly decreased, mostly less than 90 dB HL. Patients with hyperacusis may also be divided into those hypersensitive to the loudness of sounds with a decreased pure tone uncomfortable loudness level and those hypersensitive to certain specific sounds irrespective of loudness showing relatively high pure tone uncomfortable loudness levels and decreased uncomfortable loudness levels to specific sounds. With a careful history other conditions with the symptom of hypersensitivity to sound can be excluded.

A rating scale for psychotic symptoms (RSPS) part I: theoretical principles and subscale 1: perception symptoms (illusions and hallucinations)

The authors present a new rating scale for the psychotic symptoms of schizophrenia and related psychoses. The scale links specific symptoms of psychopathology to dysfunction and overactivity of dopaminergic mechanisms underlying the processes of reward and selective attention. The Rating Scale for Psychotic Symptoms (RSPS) is a 44-item rating instrument with a seven-point severity scale for each item. Psychotic symptoms are classified into three groups: Pathological amplification of mental images (perception symptoms) (subscale 1), Distraction symptoms (including catatonia and passivity experiences) (subscale 2), and Delusions (subscale 3). A dimensional, rather than a categorical, conceptualization of psychosis is assumed. Rating is accomplished through a manual and a semi-structured interview (SSCI-RSPS). In this first of two papers, general issues about the construction of the scale and the derivation of symptom groups are discussed. Dopamine-mediated modification of cortico-striatal synapses is seen as being of critical importance in all three groups of symptoms. In this first paper, we present subscale I (perception symptoms), which includes both amplified perceptual images (illusions) and hallucinations. A total of seven illusions and 11 hallucinations are rated as individual items.

Object identification deficits in dementia of the Alzheimer type: combined effects of semantic and visual proximity

Identification deficits in dementia of the Alzheimer Type (DAT) often target specific classes of objects, sparing others. Using line drawings to uncover the etiology of such category-specific deficits may be untenable because the underlying shape primitives used to differentiate one line drawing from another are unspecified, and object form is yoked to object meaning. We used computer generated stimuli with empirically specifiable properties in a paradigm that decoupled form and meaning. In Experiment 1 visually similar or distinct blobs were paired with semantically close or disparate labels, and participants attempted to learn these pairings. By having the same blobs stand for semantically close and disparate objects and looking at shape-label confusion rates for each type of set, form and meaning were independently assessed. Overall, visual similarity of shapes and semantic similarity of labels each exacerbated object confusions. For controls, the effects were small but significant. For DAT patients more substantial visual and semantic proximity effects were obtained. Experiment 2 demonstrated that even small changes in semantic proximity could effect significant changes in DAT task performance. Labeling 3 blobs with "lion," "tiger," and "leopard" significantly elevated DAT confusion rates compared to exactly the same blobs labeled with "lion," "tiger," and "zebra." In conclusion both visual similarity and semantic proximity contributed to the identification errors of DAT patients.

Negative and positive dimensions of schizotypal personality disorder

The positive (perceptual-cognitive) and negative (social-interpersonal) dimensions of schizotypal personality traits were examined in biological relatives of individuals with Axis I disorder. The subjects were young adult offspring from three contrasting parental groups, including schizophrenic disorder, affective disorder, and normal controls. Cognitive correlates, including digit span (presumed to assess working memory) and P3 amplitudes, were also examined. Preliminary results showed that positive and negative dimensions were distinguished by different prevalence patterns in the offspring subjects, and by a different pattern of correlations with cognitive measures. Negative dimensions were more frequent in offspring from the schizophrenic parental group than in the offspring from affective disorder and normal control parental groups. Digits forward and backward, and P3 amplitude decrements, characterized a subset of offspring with negative features from the schizophrenic parental group. Positive dimensions did not differ between the psychiatric parental groups, and did not covary with digit span or P3 amplitude assessments. These results support the view that positive and negative dimensions may reflect separable pathophysiologic processes.

[Dissociations between music and language functions after cerebral resection: A new case of amusia without aphasia]

We present the neuropsychological study of a patient, I.R., who sustained bilateral damage to the temporal lobes and to the right frontal lobe as a result of successive brain surgeries that occurred ten years earlier. The patient is 40 years old and right-handed; she had no special training in music or in language, representing, therefore, the large majority of listeners. Her performance is compared to that of four neurologically intact subjects who are closely matched in terms of education, sex and age. In the present study, we report I.R.'s performance on various tests aiming at assessing her general cognitive functioning with a particular focus on auditory aspects. The results show that, despite extensive damage to her auditory cortex, I.R.'s speech abilities are essentially intact (see Tables 1 and 2). The only impairments that are detected in the language domain are related to a short-term memory deficit, to some abnormal sensitivity to retroactive interference in long-term memory (see Table 3) and to articulation. These difficulties do not, however, affect linguistic communication, which is obviously undisturbed I.R. is not aphasic). Similarly, I.R. does not experience any difficulty in the recognition and memorization of familiar sounds such as animal cries, traffic noises and the like (see Tables 5 and 7). In contrast, I.R. is severely impaired in most musical abilities: She can no longer discriminate nor identify melodies that were once highly familiar to her; she can no longer discriminate nor memorize novel melodies (see Table 4). Her pattern of musical losses is compatible with a basic and severe perceptual deficit that compromises access to and registration in memory systems. The observation that the auditory impairment affects music and spares language and environmental sounds refers to a neuropsychological condition that is known as music agnosia. I.R. represents, to our knowledge, the fourth case of music agnosia available in the literature (Peretz et al., 1994; Griffiths et al., 1997). The existence of such cases suggests that music processing is not mediated by a general-purpose auditory architecture but by specialized cortical subsystems. Not only does I.R. suffer from music agnosia, but she is also impaired in the discrimination and recognition of musical instruments and of human voices (see Table 5). These latter two deficits probably do not result from the music agnosic condition. Rather, they seem to reflect damage to adjacent brain areas that are specialized in timbre processing (see Peretz. et al., 1994, for the relevant discussion). It is also worth mentioning that I.R. appears to be impaired in musical expressive abilities as well: I.R. can no longer sing a single note. Thus, her losses are rather general in the musical domain, hence justifying the classification of her case as amusia. Cases of amusia without aphasia are relatively frequent in the neuropsychological literature. However, all of these reported cases are anecdotal. Thus, in the present study, special focus is given to the measurement and direct comparison of performance in the language and music domain; in both domains, task characteristics and materials were as similar as possible. To this aim, the lyrics and the tune of the same popular song excerpts were used. The musical and the spoken parts were presented separately in a primed familiarity decision task and in a memory recognition task. In both situations, I.R. performs at or close to chance when she has to deal with music, whereas she recognizes easily and performs normally on the spoken material (see Tables 6 and 7). These results clearly argue for the autonomy of music and language in the processing of auditory information.

Developmental apraxia of speech: I. Descriptive and theoretical perspectives

Developmental apraxia of speech (DAS) is a putative diagnostic category for children whose speech errors presumedly (a) differ from the errors of children with developmental speech delay (SD) and (b) resemble the errors of adults with acquired apraxia of speech. The studies reported in this series (Shriberg, Aram, & Kwiatkowski, 1997a, 1997b) concern both premises, with primary focus on the first--that children with DAS can be differentiated from children with SD on the basis of one or more reliable differences in their speech error profiles. Immediate goals are to identify a diagnostic marker for DAS and to consider implications for research and clinical practice. A long-term goal is to identify the phenotype marker for DAS, on the assumption that it may be a genetically transmitted disorder. This first paper reviews relevant descriptive and theoretical perspectives. Findings from a local ascertainment study support the clinical functionality of the term suspected DAS.

[Are self-perceivable neuropsychological deficits in patients with neuroses or personality disorder diagnoses indicative of later schizophrenia?]

For the first time, the present study assessed the achievable predictive value of early self-experienced neuropsychological deficits for the fater development of schizophrenia. Ninety-six patients with DSM-III-R diagnoses mainly of the formerly neurotic or personality disordered field, of whom 81% had shown such basic disorders at the time of the index examination and therefore were classified as persons at high risk of developing schizophrenia, were re-examined for schizophrenia. After an average follow-up period of about 8 years, more than half of the re-examined sample had developed a schizophrenic disorder according to DSM-III-R. The outcome of schizophrenia versus no schizophrenia was predicted correctly in 77% of cases by the presence or absence of self-experienced disturbances of perception, thought, speech or action.

Phenomenology of simple partial seizures

Based on a sample of 325 inpatients we present the subjective experiences during simple partial seizures. In a majority of cases, auras comprised composed forms of different symptomatic qualities. We describe rules which seem to govern sequences of aura phenomena. Autonomous and vestibular sensations were shown to have preceding positions related to others, olfactory and gustatory sensations preferred a following position. The tentative explanation of the findings favours the idea of heterogeneity rather than the concept of a focal discharge in a simple partial seizures.

Stimulus configuration and context effects in perceptual organization in schizophrenia

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Dot Enumeration Perceptual Organization Task (DEPOT): evidence for a short-term visual memory deficit in schizophrenia

The Dot Enumeration Perceptual Organization Task (DEPOT) evaluates the validity of 2 specific competing cognitive models of early input dysfunction in schizophrenic individuals: a primary Stage 1, sensory store, perceptual organization deficit vs. a Stage 2, short-term visual memory (STVM) deficit. DEPOT was also designed to assess the hypothesis that schizophrenic individuals tend to perform poorly on all cognitive tasks. In DEPOT both number and form judgments are made about the same dot patterns. A response delay manipulation assesses the persistence and operation of STVM. The study included 41 psychotic inpatients (8 with acute and 16 with chronic schizophrenia and 7 with bipolar and 10 with nonbipolar affective disorder) and 38 controls (22 college students and 16 hospital personnel). Although the pattern of results was consistent with neither the Stage 1 deficit nor the general deficit hypotheses, a Stage 2, STVM deficit hypothesis could account parsimoniously for the data.

Is face recognition 'special'? Evidence from neuropsychology

Is face recognition 'special,' in the sense of relying on functionally and anatomically distinct mechanisms from those required for other kinds of pattern recognition? A number of different neuropsychological dissociations involving recognition and learning of faces and nonface objects are reviewed. In addition, studies of the nature of shape representation in normal face and object recognition are reviewed. The evidence from brain-damaged and normal subjects suggests that face recognition is, indeed, 'special,' and provides some clues to the functional differences between face and object recognition.

Principal identifying features of the syndrome of nonverbal learning disabilities in children

The identifying features of the syndrome of nonverbal learning disabilities (NLD) were examined with a view to determining their relative discriminant validity. A stepwise linear discriminant function analysis of children with NLD (n = 29), children with reading and spelling disabilities (Group R-S; n = 27), and a group of nonclinical children (NC; n = 27) on 15 neuropsychological variables yielded a subset of scores on four tests (Target Test; Trail Making Test, Part B; Tactual Performance Test; and Grooved Pegboard Test) that accurately (> 95%) discriminated the NLD group from the R-S and NC subjects. Of the neuropsychological features of NLD described by Rourke (1987, 1988b, 1989), deficits in visual-perceptual-organizational psychomotor coordination and complex tactile-perceptual skills appeared to be most representative (in the sense of most discriminative) of the NDL syndrome in the children examined. These are also the dimensions that are considered to be "primary" in the NLD model (Rourke, 1989). Replication of these results, employing children with other clinical disorders, is necessary.

The meaning of basic symptoms for the genesis of the schizophrenic nuclear syndrome

In the Bonn Transition Sequences study, the development of the Schneiderian first rank symptoms in their exact chronological order was studied from the first symptomatological precursors up to the complete forms of the respective psychotic final phenomena. At their onset, subjective experiences of preexisting disorders of perception, thinking, speech and memory, of cognitive control of action and of proprioception were found. These four groups of initial deficiencies developed via certain intermediate phenomena into first rank symptoms. The analysis of these transition sequences revealed three phases with different generating factors each. Altogether, the results showed that and how the gap between the deficiency findings of the biologically oriented research in schizophrenia and the diagnostically relevant changes in experience can be bridged.

Towards the unification of body image disorders

In the course of this discussion of body image disorders there has been little opportunity to discuss culture bound disorders although of course it should not be overlooked that obesity, anorexia and bulimia nervosa are to some extent culture bound, but prevalent within our own society. There are many different specific syndromes presenting with physical symptoms, often based upon hypochondriacal concern about the body. For example, koro which occurs in South East Asia presents with an overwhelming preoccupation that the penis will retract into the abdomen and hence cause death; there is thus both a fear for virility and a fear for life. Can there be unification of these very different concepts? Although the answer is probably negative, classification becomes more meaningful if epistemological unity is achieved, and phenomenological psychopathology is the most likely root to achieve this. There is therefore a need to concentrate upon the precise description of the patients' own internal experience, using this for categorisation of the symptoms. Objectivity has been held up in medicine as the ideal; however, in order to make progress in this area there is a need to structure subjectivity. Body image, as the concept of the body, is a part of self image; ultimately the only way to explore the self is to study self description using empathy as a diagnostic instrument.