Ventromedial prefrontal cortex modulates fatigue after penetrating TBI

Pardini M, Krueger F, Raymont V, Grafman J.  Neurology 2010; 74:749-754.

97 PBI patients and 37 controls from Vietnam Head Injury Study were enrolled.  Fatigue was assessed via questionnaires (Krupp Fatigue Scale).  CT scan localization of lesions was made to nonfrontal, ventromedial prefrontal, and dorsolateral /lateral prefrontal.  All 3 areas were associated with fatigue, but only VM was associated with increasing fatigue with larger lesion volume.  Authors note this may allow linkage of fatigue to other ventromedial functions such as  effort and reward participation. 

Note one of references was a John Deluca functional MRI paper showing role for same area in MS related fatigue J Neurol Sci 2008; 270:28-39.

Cognitive effects of pregabalin in healthy volunteers

a double blind, placebo controlled trial  Salinsky M, Storzbach D, Munoz S.  Neurology 2010; 74: 755-761.

32 healthy volunteers were randomized to pregabalin (300 bid) or placebo for twelve weeks and underwent cognitive tests before and after.  Subjects on pregabalin showed worse performance on 3 of 6 target cognitive measures, including digit symbol test, Stroop, and Controlled Oral Word Association Test.  They were paralleled by changes on the Portland Neurotoxicity Scale.

Parcelling frontal functions

Van Snellenberg JC, Wager TD.  Cognitive and motivational functions of the human prefrontal cortex.   from Christensen AL, Goldberg E, Bougakov D.  Luria's Legacy in the 21st Century. Oxford, University Press, 2009.  pp. 30-61.


Chapter summarized authors' (esp Wager's) meta-analyses of functional imaging studies.  These involve working memory, task switching, response inhibition, and emotion. cites Stuss and Alexander, 2007. See chapter.

Luria-- Semantic fragments for repetition and recall

These stories have layers of meaning and complexity

1. Tolstoy's  The Hen and the Golden Eggs-  A man had a hen which laid golden eggs.  He wanted to get more of the eggs at once, and so he killed the hen.  But inside he found nothing; it was just a hen like any other.

2.  Tolstoy's The jackdaw and the Pigeons.  A jackdaw heard that some pigeons had plenty of food.  She painted herself white and flew into the pigeons house.  The pigeons thought she was a pigeon, and took her in.  However, she forgot herself and cried like a jackdaw.  The pigeons then realized she was a jackdaw and sent her away.  She went back to her family, but they did not recognize her, and would not have her either.

3.  Tolstoy's The Ant and the Pigeon.  An ant went down to the stream to drink.  A wave swamped him and he began to drown.  A pigeon flew past him and threw him a  twig.  He climbed on the twig and was saved.

The next day, a hunter set a net and caught the pigeon.  When he took it from the net, however, the ant crawled up stealthily and bit the hunter on his hand.  The hunter cried out and the pigeon flew away. 

4.  The Lion and the mouse.  A lion was asleep and a mouse ran over his body.  The lion awoke and caught the mouse.  The mouse begged him to let her go.  The lion laughed and let her go.  The next day, a hunter caught the lion and tied him with a rope to a tree.  The mouse came through stealthily, gnawed through the rope, and set the lion free.

5.  The Lion and the Fox.  The Lion grew old and  could no longer hunt animals.  So the lion had to learn how to live by cunning.  He lay in his den and pretended to be ill.   The animals came up to him and he ate them.  One day a fox came but would not go into his den.  The lion asked her "Why don't you come in?" The fox replied, " I can see tracks coming into your den but none coming out." 

6.  The Stupid Dog.  A dog was walking over a bridge at night and saw the reflection of the moon in the water. The dog decided it was cheese and jumped into the water.  But of course, she found nothing and only got wet.



Results  patients who had trouble recalling individual words sometimes had no trouble with semantic fragments, and normals had no trouble with 2 successive fragments.  Amnesics would present the semantic content of one part of the story but forget the second part (retroactive inhibition). 

Luria-- sentence repetition-- aphasia or amnesia??

AR Luria.  The Neuropsychology of Memory VH WInston and Sons, Washington , D.C. 1976 p. 103

Patients with vascular lesions could repeat one sentence, had trouble with the second one.  Patient either reverts to first sentence or contaminates elements, displaying "recency effect" but also simplifying the structure of the sentence while maintaining its elements.  However, patients with temporal lesions showed no "freezing or inert repetition" as in frontal lesions.

Sentence recall-- Luria

Although list learning requires multiple presentations, normals can easily recall one and then a second 7 or 8 word sentence (simplified if aphasic) and then repeat both sentences in order. 

Examples
first sentence:  "Apple trees grew in the garden  behind the high fence" or "The hunter killed a wolf on the edge of the forest.  "  Second sentence  :  " In Tashkent there was an earthquake and many houses were destroyed" or "In Tushino there was an air display and parachute jumps." 

Simpler versions "The boy is cold" or "the girl is asleep" or "the boy hit the dog" or "the girl drinks tea"

Results: Amnesics could repeat the sentences immediately, or after empty or filled pauses, with some trouble if the pause was filled with rapid speech.  However, when given a second sentence, they either lost the first or mixed up the elements. 

Disturbance of seriality due to left temporal lesions

Luria in Neuropsychology of memory states that left temporal lesions cause a disturbance of retroactive inhibition in which the last word of the list inhibits recall of predecessors on the list, especially with longer lists.  The effect only occurs with lists presented and reproduced verbally.  Luria gives original credit to Lashley

Lashley KS.  Functional determination of cerebral localization.  Arch Neurol Psych 38: 1937.

Learned motor responses.

Subject is asked to raise his left hand to one tap, and his right hand to 2 taps, or to raise his hand to one tap and to refrain from raising his hand to 2 taps. 

More complicated version: patient is asked to respond to a fist with a finger, or to a finger with a fist.  Or, he is asked to responnd to two taps with one tap, and to one tap with 2 taps. 

More complicated yet.  the subject is asked to respond to a weak tap with a powerful hand movement, and to a powerful tap with a weak hand movement.  Or, to respond to a short acoustic stimulus with a slow movement, and a long stimulus with a prolonged movement. (cf  Marushevskii M, Disturbance of the simplest forms of voluntary action in local lesions of the frontal lobes.  in Luria AR, Khomskaya ED (eds), The frontal lobes and the regulation of psychological processes. Moscow, MGU Press, 1966.

Luria's adaptation:  He would give one task, and when mastered give a second, then without repeating instructions, go back to the first, and then the second task.  Normals had little trouble either learning the task or switching.  Neither empty or filled paused had much effect, (except occipital lesions for visual tasks and temporal lesions for auditory tasks).  Massive tumors had problems with task. 

Patients with thalamic lesions could learn the task, but not do it verbally.  These patients learned the task, were not affected by interference, but could not talk about it. 

Unadze illusion fixed set test

From Luria's book Neuropsychology of  Memory

Unadze DN.  Experimental psychological investigations.  Moscow.  Nauka.  1966.

A subject is given 2 balls of different sizes to squeeze (one per hand) 10-15 times for several seconds per squeeze.  He compares their sizes and reports his finding.  Then, without visual inspection he is given 2 balls of equal size and asked to compare the sizes.  The result is that the hand that held the larger ball now reports it is holding a smaller ball, and is maintained even after 12-18 trials.

Luria's variation was to test normal, mildly and severely impaired subjects on the test.  He found that in severely amnesic subjects only, and only with interference, the fixed set effect was achieved but rapidly forgotten, underlying the importance in interference on somatic memory. Pauses less than 2 minutes had little effect on retention, as with other types of learning.

Gerstmann's syndrome reader

Kombos T,  Picht t, Suess O.  Electrical Excitability of the Angular Gyrus. Journal of Clinical Neurophysiology 25(6) December 2008 .
Comment.  This is the first report of direct electrical stimulation of AG in humans. Stimulation resulted in responses in contralateral upper extremity in 3/5 patients.  No lower extremity stimulation was found.


Anema HA.a,  Kessels RPCcd, de Haan EHFe,  Kappelle L,  Leijten F, van Zandvoort Martine , Dijkerman,H.  Differences in finger localisation performance of patients with finger agnosia

 19(14) September 2008 . 
Comment : 3 patients with AG lesions were able to point with their finger effectively
to  a tactile stimulus (body schema intact) but unable to do so with a drawing  of hand or to name the finger. 
Other body parts did not have this dissociation between body schema and body image.

Tamura I, Kikuchi S, Otsuki M, Tashiro K. The writing of arabic numerals, kanji, and kana in brain-damaged patients. 14(6), 6 May 2003, pp 861-865.
Comment.  4 patients with Gerstmann's syndrome and 4 with Wernicke's aphasia were compared.  All patients could copy letters, and were righthanded.  Subjects were presented with coins, and then asked to write the respective number value in kana , Kanji and Arabic numerals. For GS patients, kanji writing was better than Arabic, that was better than kana writing.  For WA aphasia patients, Arabic numeral writing was better than kana and kanji. Discussion: "In the case of GS, there was a problem in the concept of number.  In the case of WA, the concept of number was relatively well preserved." GS subjects made substitution errors in Arabic number writing.  Authors postulate a deficiency processing recall of somesthetic graphemes linked to the  concept of number.


Wingard E, Barrett  A, Crucian G, Doty, L, Heilman, KM.  The Gerstmann syndrome in Alzheimer's disease. Journal of Neurology, Neurosurgery & Psychiatry  72(3) March 2002 .
Comment  :  among 38 patients with Alzheimer's disease, the four constituent components of Gerstmann's syndrome did not cluster together, leading the authors to speculate that their association is fortuitous due to contiguous networks, and that the four features of Gerstmann's syndrome do not share a common network.

Baciul M, Koenig O, Vernier M,  Bedoin N, Rubin C, Segebarth C. Categorical and coordinate spatial relations: fMRI evidence for hemispheric specialization. Neuroreport 10(6) April 1999.
Comment: 16 healthy males were examined on a coordinate and a category task using fMRI paradigm.  The category task was whether a dot was above or below a horizontal line. The coordinate task was whether the distance between the dot and the line was within a reference distance.  The coordinate task related to right AG activation which decreased over time.  The category task depended upon Left AG activation which did not decrease over time and in fact increased over time.  Results subserve the hypothesis that the left hemisphere subserves the development of new spatial categorization.

Cognition and Fragile X syndrome

Fragile X problems persist into adulthood (even though it is considered a pediatric disease). Two separate conditions exist. Patients with the premutation (55-200 repeats of the FMR1 gene) have RNA toxicity but not full blown cognitive abnormalities. RNA toxicity can include primary ovarian insufficiency, fragile X associated tremor ataxia syndrome (FXTAS), fibromyalgia, hypothyroidism, and psychiatric issues such as anxiety and depression. Boys in this range can experience shyness, social anxiety disorders, ADHD and autism spectrum disorders. This is due to excess FMR1 gene.

Patients with the full mutation (greater than 200 repeats) have LACK of FMR1 and Fragile X syndrome (opposite of above in which there is excess RNA present). They present with severe cognitive abnormalities. In boys this manifests as autism, in girls as severe learning disabilities. They also have connective tissue disorders, agression, and psychiatric problems as above. Males with FXS usually have IQ below 70 (severe) but 15 % are "high functioning" with IQ above. High functioning is due to mosaicism within cells or within methylation and the degree of impairment is related to the amount of FMRP present. Among girls, 40 % have a normal IQ, 35 % are borderline, and 25 % have an IQ below 70. The activation percentage (pct of normal X that is active) correlates with disease and that and amount of FMRP available also affects functioning of offspring.

FXS is the most common cause of intellectual impairment and of autism spectrum disease. The full mutation occurs in 1:2500 in population, and the premutation occurs in 1:250 girls and 1:800 boys in the general population. Genetics: FXS patients always have their mother as a carrier. Fathers often pass the premutation on, to their daughters and it does not expand to a full mutation. Mothers with premutation often have expansion to full mutation in their offspring, especially if the number of repeats is greater than 100.

See also posts on FXS and FXTAS on www.neurologyminutiae.blogspot.com

Cognition and dystrophinopathy

Duchenne's muscular dystrophy has associated delayed milestones especially language, global cognitive impairment, and occassionally autism. Becker's muscular dystrophy has less common findings, but also, compared to general population, has more learning disabilities with normal intelligence, autism, attention and behavioral problems. Orofacial problems may occur.

Botteron S, Verdabout CM, Jeannet PY, Kiliardis S. Orofacial dysfunction in Duchenne Muscular Dystrophy. Arch Oral Biol 2009; 54(1): 26-31.

Cyrulnik SE, Fee RJ, De Vivo DC, et al. Delayed developmental language milestones in children with Duchenne's muscular dystrophy. J Pediatr 2007; 150 (5): 474-478.

Hinton VJ, Fee RJ, Goldstein EM, De Vivo DC. Verbal and memory skills in males with Duchenne muscular dystrophy. Dev Med Child Neurology 2007; 49 (2): 123-128.

Young HK, Barton BA, Waisbren S, et al. Cognitive and psychological profile of males with Becker muscular dystrophy. J Child Neurol 2008; 23 (2): 155-162.

Luria audiomotor integrative tasks

Pitch tests should be kept simple, give 2 sounds ask which is higher or lower.

reproduction of tones

reproduction of rhythmic taps first by imitation, then by verbal instruction, then by reproduction with verbal enforcement



Tactile functions p. 444

discriminative sensation "epicritic" (Head, 1920).
Ideas test with head and point of pin, patient must discriminate which, or use 3 items and ask patient to discriminate. Localize touch by asking patient to point to spot, and make it harder by asking him to point to same spot on the opposite limb. Use Weber's touch compass to discriminate 2 point differentiation threshold in millimeters. Also use it to differentiate Double simultaenous stimulation which is difficult in patients with right parietal injury. Finally measure up and down movements and ability to trace numbers and letters in the hand. Cites Teuber, 1959. Notes that lesions is left hemisphere for are tightly organized in postcentral area, but right hemisphere lesions are more distributed and even left hemisphere lesions occassionally cause left arm abnormalities.

Kinesthetic function (position sense)
simple move a finger, toe, arm and ask whether its up or down (or mimic with other side)
More complicated-- mimic posture in the other hand.

Asterognosis
differentiates from amorphosythesis (denny brown 1952, 1958).

More Luria tests

from "Higher Cortical Functions in Man" p. 428

Complex motor functions

1. Reaction tests-- basic format is for subject to raise his hand in response to a tap or another stimulus. This then can be the basis of more complex tests.
Abnormalities are rarely seen with simple reaction tests, exceptions being "freezing" in position in htn, motor impersistence in frontal lesions, or premature responses in frontal lesions.
Next step is to respond alternately, eg. raise the left hand to one tap, and the right to two taps, or raise the hand with one tap and refrain from moving the hand with two. Start with strict alternating pattern, eg a-b-a-b-a-b- then suddenly break the stereotype and go out of order eg b-b and see what the patient does. Alternately, can ask for an oral answer to a stimulus eg. to one tap, say "I must" or "left" and to 2 taps "I must not" or "right." The third stage is to tell the subject to respond orally and perform appropriate motor action at same time (cites Kohomskaya, 1956, 1958). Then give a complex response, eg to one stimulus give a weak response, and to another a strong response of same hand.

2. " Raise finger if I raise fist, and fist if I raise my finger"
3. Ask patient to copy a series of figure eg. circle, triangle, square and cross, then a second series eg square square triangle, cross and see if they perseverate. May use five elements. May see forget last response, perseverate, not remember etc. Temporal lobe lesions may make it difficult to copy to verbal instruction but OK to copy from sight. Differentiate the two by asking patient to repeat the command before performing it.

4.

Apathy with subthalamic stimulation (and face recognition)

apathy evaluation scale
http://www.tbims.org/combi/aes/AES.PDF

Le Jeune et al. Neurology 2009; 73:1746-1751.

Studied STN stimulation in PET study. All had bilateral STN implantation. 12 patients showed worse apathy 3 months after STN stimulation. Motor function was used. The AES was used. PET showed positive correlation with right Brodmann's areas 10 (r frontal middle gyrus) and area 46 (R IFG) and negative correlation with right posterior cingulum (are 31) and left media frontal lobe ( area 9).

Postop neuropsych differed on WCST perseverative errors and Stroop.

raloxifene improves verbal memory in postmenopausal women

Raloxifene improves verbal memory in late postmenopausal women: a randomized, double-blind, placebo-controlled trial; Jacobsen DE, Samson MM, Emmelot-Vonk MH, Verhaar HJ; Menopause (Nov 2009)

OBJECTIVE:: The aim of this study was to examine the effects of raloxifene compared with those of placebo on verbal memory, mental processing speed, depression, anxiety, and quality of life. METHODS:: A randomized, double-blind, placebo-controlled trial of 213 healthy women 70 years or older was conducted between July 2003 and January 2008 at the University Medical Centre Utrecht, the Netherlands. Participants were randomly assigned to receive raloxifene (60 mg) or placebo daily for 12 months. Measurements were taken at baseline and after 3, 6, and 12 months. The change in scores from baseline was calculated. The main outcome measures were direct and delayed verbal memory (Groningen 15 Words test), mental processing speed (Trails B test), mood/depression (Geriatric Depression Scale), anxiety (State-Trait Anxiety Inventory 1 and 2), and quality of life (Women's Health Questionnaire and EuroQol-5 dimensional questionnaire). RESULTS:: Direct verbal memory improved significantly with raloxifene compared with placebo: the women receiving raloxifene repeated more words in the words A + B test than did the women receiving placebo (P = 0.025). At 12 months, the change from baseline was 16 words in the raloxifene group and 10 words in the placebo group. In the words A test, direct repetition was also significantly better among women receiving raloxifene than among women receiving placebo (P = 0.023), with the change from baseline in the number of words repeated being nine words in the raloxifene group and six words in the placebo group at 12 months. CONCLUSIONS:: In postmenopausal women, raloxifene gave significantly improved verbal memory when compared with placebo.

WHIMS MRI study brain atrophy and estrogen

NEUROLOGY 2009;72:135-142

 

1403 women aged 71-89, a subset of WHI trial, were scanned on average four years apart.  Frontal lobe volume was less at followup in women in estrogen or estrogen plus progesterone arms.  Temporal lobe and total brain volume were not affected as markedly. The adverse effects are most evident in women experiencing cognitive deficits before initiating hormone therapy.

The cognitive measure used was the modified MMSE 3M

18. Teng EL, Chui H. The Modified Mini-Mental State (3MS) Exam. J Clin Psychiatry 1987;48:314–318.

Confabulation and other delusional syndromes

Confabulation is usually associated with memory (medial temporal or diencephalic) and executive (bifrontal) dysfunction.^7-9

 

7. Benson DF, Djenderedjian A, Miller BL, et al. Neural basis of confabulation. Neurology 1996;46:1239–1243.[Abstract/Free Full Text]
8. Moscovitch M, Melo B. Strategic recall and the frontal lobes: evidence from confabulation and amnesia. Neuropsychologia 1997;35:1017–1034.[Medline]
9. Johnson MK, Hayes SM, D'Esposito M, Raye CL. Confabulation. In: Grafman J, Boller F. Handbook of Neuropsychology,

The anterior parahippocampal cortex (perirhinal cortex, Brodmann areas 35 and 36) is activated by familiarity, while the hippocampus and posterior parahippocampal cortex mediate recollection.⁴⁹ Perirhinal cortex stimulation evokes déjà vu and déjà vécu (already experienced).⁵⁰ Further, the right hemisphere dominates in familiarity decisions^14,48; déjà vu is more common with right than left temporal lobe seizures or stimulation.^48,51 Lesions that destroy or isolate stimuli from right perirhinal cortex may lead to loss of familiarity (e.g., Capgras syndrome) while hyperfamiliarity (i.e., misidentifying strange people as familiar [Fregoli syndrome]) may result from overactivity in right perirhinal cortex from stimulation or disinhibition. Two cases of nondelusional hyperfamiliarity for faces resulted from left-sided lesions (lateral temporal-occipital and anterior cingulate),^52,53 possibly disinhibiting right hemisphere areas that imbue faces or places with familiarity.

48. Gainotti G. Face familiarity feelings, the right temporal lobe and the possible underlying neural mechanisms. Brain Res Rev 2007;56:214–235.[Medline]
49. Bowles B, Crupi C, Mirsattari SM, et al. Impaired familiarity with preserved recollection after anterior temporal-lobe resection that spares the hippocampus. Proc Natl Acad Sci 2007;104:16382–16387.[Abstract/Free Full Text]
50. Vignal J-P, Maillard L, McGonigal A, Chauvel P. The dreamy state: hallucinations of autobiographic memory evoked by temporal lobe stimulations and seizures. Brain 2007;130:88–89.[Abstract/Free Full Text]
51. Mullan S, Penfield W. Illusions of comparative interpretation and emotion. Arch Neurol Psychiatry 1959;81:269–284.[Abstract/Free Full Text]
52. Vuilleumier P, Mohr C, Valenza N, Wetzel C, Landis T. Hyperfamiliarity for unknown faces after left lateral temporo-occipital venous infarction: a double dissociation with prosopagnosia. Brain 2003;126:889–907.[Abstract/Free Full Text]
53. Nente F, Carrillo-Mezo R, Mendez MF, Ramirez-Bermudez J. Pathological hyperfamiliarity for others from a left anterior cingulate lesion. J Neuropsychiatry Clin Neurosci 2007;19:345–346.[Free Full Text]

Hughlings Jackson and right hemisphere expression, and callosal syndromes

56. Jackson JH. Evolution and dissolution of the nervous system. In: Taylor J, ed. Selected Writings of John Hughlings Jackson, Volume 2. New York: Basic Books; 1884/1958:45–75.
57. Sperry RW, Zaidel E, Zaidel D. Self recognition and social awareness in the deconnected minor hemisphere. Neuropsychologia 1979;17:153–166.[Medline]
58. Gazzaniga MS. Cerebral specialization and interhemispheric communication. Brain 2000;123:1296–1326.
59. Gazzaniga MS. The split brain revisited. Sci Am 1998;279:50–55.[Medline]

ego boundaries response to next patient syndrome

55. Bogousslavsky J, Regli F. Response-to-next-patient-stimulation: a right hemisphere syndrome. Neurology 1988;38:1225–1227.[Abstract/Free Full Text]

Neuropsych and carotid stenosis

M. Silvestrini, MD, I. Paolino, MD, F. Vernieri, MD, C. Pedone, MD, R. Baruffaldi, MD, B. Gobbi, MD, C. Cagnetti, MD, L. Provinciali, MD and M. Bartolini, MD . Cerebral hemodynamics and cognitive performance in patients with asymptomatic carotid stenosis. NEUROLOGY 2009;72:1062-1068

Objective: The aim of this study was to investigate whether the presence of severe internal carotid artery stenosis may be associated with different cognitive performance in relation to the side of the stenosis and its hemodynamic consequences.

Methods: Eighty-three patients with asymptomatic severe unilateral internal carotid stenosis were included. A neuropsychological investigation including Verbal Fluency using phonemic and category access, Coloured Progressive Matrices, and Complex Figure Test Copy was performed. Each patient underwent an assessment of cerebrovascular reactivity (CVR) to hypercapnia with transcranial Doppler ultrasonography using the breath-holding index (BHI). Thirty healthy subjects comparable for demographic characteristics and vascular risk profile served as controls. Subjects with carotid stenosis were classified into two groups: preserved CVR (BHI 0.69), 48 patients (25 with left and 23 with right stenosis); and impaired CVR (BHI <0.69), 35 patients (19 with left and 16 with right stenosis).

Results: Subjects with left stenosis and reduced CVR had significantly lower performances at phonemic verbal fluency with respect to controls and the other groups of stenosis. In subjects with right stenosis and reduced CVR, scores obtained in Coloured Progressive Matrices and in Complex Figure Test Copy were significantly lower with respect to the other groups.

Conclusions: These results suggest that an alteration of cerebrovascular reactivity may be responsible for reduction in some cognitive abilities involving the function of the hemisphere ipsilateral to carotid stenosis. Such findings may be of interest for providing a more comprehensive indication to surgical treatment in subgroups of subjects with asymptomatic carotid stenosis.

Devinsky on localization of Capgras, Fregoli,anosognosia and related conditions

Neurology 2009 Views and Reviews

ABSTRACT When the delusional misidentification syndromes reduplicative paramnesia and Capgras syndromes result from neurologic disease, lesions are usually bifrontal and/or right hemispheric. The related disorders of confabulation and anosognosis share overlapping mechanisms and anatomic pathology. A dual mechanism is postulated for the delusional misidentification syndromes: negative effects from right hemisphere and frontal lobe dysfunction as well as positive effects from release (i.e., overactivity) of preserved left hemisphere areas. Negative effects of right hemisphere injury impair self-monitoring, ego boundaries, and attaching emotional valence and familiarity to stimuli. The unchecked left hemisphere unleashes a creative narrator from the monitoring of self, memory, and reality by the frontal and right hemisphere areas, leading to excessive and false explanations. Further, the left hemisphere's cognitive style of categorization, often into dual categories, leads it to invent a duplicate or impostor to resolve conflicting information. Delusions result from right hemisphere lesions. But it is the left hemisphere that is deluded.

(from text of article in Neurology)

Reduplicative paramnesia and Capgras syndrome cases with unilateral brain lesions strongly implicate the right hemisphere, usually frontal with variable temporal or parietal involvement.

^{Other points of interest}

Luria tests from Higher Cortical Functions in Man

Motor:
p.417 and on
1. copy hand postures- suggested to do with little visual input.
2. bimanual task-- closes patient eyes, places one hand in posture and asks patient to place opposite hand in same posture.
3. cites Head's test with mirror image imitation and imitation with same (ie left or right hand). Also, do imitation while touching left eye, right ear etc.
4. cites Ozeretskii (1930)- place one hand in fist, the other outstretched and alternate movement (premotor)reciprocal coordination
5. Place both hands in front, alternately tap twice with right hand, once with the left, with smooth transitions, and then switch the sides. Request the test to be done quickly.
6. Ozeretskii again- if one hand is paretic, do "fist ring" of other hand, thrust hand forward alternately making a fist, and a ring, testing premotor again.
7. Eidinova and Pravdina-Vinarskaya-- (1959)-- Start with a bent elbow, straight fingers, and ask patient to extend elbow, and at same time change hand position to a fist, rapidly. repeating. May eventually change the instruction to the opposite.
8. More difficult-- fist edge palm
9. Piano imitation-- ask patient on table to imitate playing piano with thumnb and first finger of one hand, and fingers 1-5 of other at same time. (and various combinations).
10. Doing above tasks with self spoken cues
11. writing alternating components (Russian equivalent of m and n)
12. Observation of everyday tasks (buttoning, lacing a shoe)
13. States that performance of imaginary acts such as pouring tea are sensitive but not equally susceptible to analytics.

Oral praxis p 425
1. Basic exam-- if patient can bare teeth once, ask him to sustain task for a long time.
2. touch tongue to upper lip, protrude it and keep it out for a while, looking for synkinesis, smoothness of movement
3. Stretch lips, roll up tongue, puff the cheeks and alternate these.
4. "Integrative tests" are chewing, spitting, kissing and whistling
5. Rid mouth of actual edible food which may be impossible even though above are preserved.

Selnes and Gordon: Quick office neuropsych testing

A few novel suggestions by these two:
Orientation: Add time of day to questions to increase sensitivity
Attention: Use forward-reverse digit span rather than serial sevens
Memory-- NCSE (AnnInt Med) 1987 uses 4 words and a recognition memory function is better than three words recall.
Language-- use brief screening test, progress to more difficult
Visuoconstruction-- draw a clock face or Necker cube is better than copy test of MMSE
Perceptualability-- tell time from clock face
Frontal lobe-- 3 hand test of Luria no suggestions
Psychomotor speed-- write alphabet as quickly as possible. Normal isless than 20 seconds, abnormal ismore than 30 seconds.

Clock Drawing Test notes on

The test incorporates a broad range of cognitive requirements making it an effective screening instrument. These include comprehension, planning, visuoconstruction abilities, motor programming, numerical knowledge, abstract thinking, and concentration.

There are several different tests that are used. One test, using a predrawn circle is standard for some, whereas others use a requirement for the subject to draw the circle. In typical case, subjects are given a circle and asked to place the hands at ten minutes past eleven.

In the Boston Diagnostic Aphasia battery, subjects are given four predrawn clocks, with ticks for the hours and asked to mark each clock to a different time: 1:00, 3:00. 9:15 and 11:30. One point is awarded for placing the hands in correct place, another for correct hand lengths, with three points per clock and maximum twelve points for entire test.

Shulman used a five point scale, with five points for a perfect clock, four for minor visuospatial errors, three for inaccurate representation of 10 minutes past eleven with visuospatial organization is well done, two for disorganized visuospatia representation such that telling ten minutes past eleven is immpossible, and one for inability to discern a clock.

Shulman cited roughly 85 % sensitivity and specificity, noting that the Clock Drawing Test adds frontal, visuospatial constructive ability to MMSE.

The CLOX test is a modified test used in CERAD. The subject is given a blank paper, and told "Draw me a clock and set the hands to 1:45 so that even a child could read them." That is CLOX 1. CLOX 2 the subject is given the clock and told to copy it. On Clox 1, subjects are graded as normal, mildly, moderately, or severely immpaired.

Tests can be used in a variety of settings that are not at first blush apparent, including screening patients undergoing hip replacement surgery for postop delirium, (better than MMSE)or subtyping dementia. Curiously, vascular dementia patients make more segmentation errors on clock test than do Alzheimer's patients.

Dysfluency pearls: Stuttering, cluttering & palilalia

1. Developmental stuttering usually is made better by singing, repetitive reading of same passage (adaptation) and playing white noice in patient's own ear to prevent him from hearing his own speech . There is no neurologic lesion or evaluatin required.

2. Acquired stuttering can occur with multiple location small brain lesions and does require MRI. Unlike developmental stutterers, acquired stutterers are dysfluent throughout a sentence, not just at the beginning, and are generally not bothered or embarassed by the deficiency.

3. Cluttering is characterized by rapid speech, repetitions, omissions, interjections and disturbed prosody. Sounds and syllables may be inverted or omitted. Clutterers may repeat initia sounds and prolong sounds within the word. Clutterers are not concerned about the problem and usually do not need neurologic evaluation.

4. Palilalia is characterized by compulsive repetition of words and phrases at increasing speed and with a decrescendo phonatory volume, and occurs in Parkinson's disease and pseudobulbar palsy. It improves considerably when the patient speaks with a metronome.

Akinetopsia in posterior cortical variant of Alzheimer's

Akinetopsia is inability to perceive motion (Zeki, Brain 1991). It occurs due to bilateral lesions at posterior parieto-occipital junction. (Also see Rizzo, Brain Res., 2008). Authors (Tsai and Mendez, Neurology 2009) report 2 patients with degenerative disease that reported double vision with vision as "a series of successive stills" from moving images. Neuropsych testing showed impaired constructions of figures (Rey-Ost.), impaired figure-ground, visual synthesis, search, depth discrimination Akinetopsia was elicited with vision to LEFT and not relieved with alternate eye cover/uncover. Laterality and preference for one lateralization corresponds with primate work.

Origin of delirium in DT's

Fisher CM.  Ethanol in treatment of AWS.  The Neurologist 2009; 15: 242-244.  In category "Notes from a Legend."

 

CM Fisher writes in the Neurologist that behaviorist Watson (1925) believed the terror feeling of having one's arms and legs restrained was a primitive inborn reflex and that was re-expressed when alcoholics were restrained and became agitated.

 

In the same article, Fisher writes about the utility of intravenous and oral alcohol being superior than benzodiazepines in some moderate social drinkers who are admitted and who suffer DT's

Laterality in catamential seizures

Quigg M et al. Laterality and location influence catamenial seizure expression in women with partial epilepsy.  Neurology 2009; 73: 223-227. 

 

Authors studied 100 women enrolled in a clinical trial of hormonal therapy for localization related epilepsy  (NIH progesterone trial study group).  Extratemporal  (10), and multifocal (14) seizures occurred randomly throught the lunar cycle.  There were 5 patients with unknown seizure origin, 25 with left temporal seizures, and 29 with right temporal seizures.  Patients with left temporal seizures peaked cyclically with onset of menses, whereas right temporal lobe seizures occurred randomly.

Cerebellum and Foreign Accent Syndrome

Cohen DA, Kurowski K, Steven MS, Blumstein SE, Pascual-Leone A. Paradoxical facilitation . The resolution of foreign accent syndrome after cerebellar stroke. Neurology 2009; 73:566-67.

Background: Lesions are usually left parietal. 2 previous cases were described with cerebellar hypoperfusion that resolved with FAS .

Case: 58 yo woman had left frontoparietal infarct with aphemia and right upper limb paresis. It resolved to right arm ataxia and English with an accent. 2 years later, after a right cerebellar hemorrhagic infarct, the FAS resolved. Her speech was analysed after each stroke. Abnormalities which were detected that comprised the FAS included pathologic prosody, vowel formant freqency, vowel durations, and increased variabilities on these vowel measures, and normal voicing and placement of stop consonants and preservation of the distinction between tense and lax vowels.

Alterations in timing and rhythm of speech, as seen in FAS, are characteristic of cerebellar lesions (see Ivry R., Cerebellar timing systems, Int Rev Neurobiol, 1997; 41: 555-573). The author speculates that the prosodic problems in FAS may " reflect deficits in timing resulting in impairments of speech melody, in maintaining the correct vocal posture for the production of vowels, in maintaining the correct durational patterns of speech, and in producing syllabic stress and quantity."

Re mechanism, the authors propose that the lesioned right cerebellum then gives way to the now dominant left cerebellar hemisphere, which is disinhibited and now functional.

Visual hallunications due to cardiac carcinoid

Mekuria S, Tan C, Schoenhagen P, et al. Shortness of breath and visual hallucinations. Am J Med 2009; 122: 338-341.

Patient had exertional dyspnea, night sweats, weight loss over six months. Week prior to admission, he developed visual hallucinations including ants crawling on wall and rabbits inside his room. ECHO showed a right heart cardiac tumor, eventually with an elevated urinary 5 HIAA. Brain imaging was negative. Authors postulated hallucinations were due to serotonin from tumor entering circulation, via a patent foramen ovale. Without a right to left shunt, the lung would have metabolized serotonin (adenosine deaminase). Octeotride resulted in less hallucinations, and effects were monitored with serotonin levels. Previous behavioral neurology of carcinoid syndrome includes behavior dysregulation (see Russo et al. Psychosoma Med 2003; 66:422-425).

Problems of neurolinguistics

In his conclusion, Luria notes that the new field of neurolinguistics presents some difficulties for the would-be practitioner because it requires a skillful level of proficiency in "neurological, psychophysiological, and linguistic knowledge" ( Luria, 1974a, p. 2591).

Semantics, Phonetics and Orienting reaction

With respect to their goal of defining the dynamics and structure of the semantic system, the authors come to two conclusions:
the words are divided into three groups: (1) the nucleus of the semantic complex, to which is related the key word and words in direct semantic proximity to it (they evoke a specific pain reaction); (2) the periphery of the semantic system to which are related words linked less directly with the key word (evoking a non-specific orienting reaction); and (3) neutral words, which in our experiment did not evoke any specific or orienting reactions.
The correlation of these groups at various stages of the experiments may be different, and if at the beginning of the experiment the nucleus of the semantic system has a relatively generalized character, then later it becomes concentrated and only the key word continues to provoke a specific reaction, while the remaining words, which earlier were included in this nucleus, move into the semantic periphery and begin to evoke only a non-specific orienting reaction. ( Luria & Vinogradova, 1959, pp. 99-100)

Traumatic Aphasia Scheme

While others might speak of aphasias in general, Luria presents his own organizational schema. First of all, he groups aphasias into three basic groups according to severity: (1) Total Aphasia is characterized by a total block of production and/or comprehension of speech. The disturbance is severe and lasts at least two or three weeks. (2) Well Expressed Aphasia includes those cases where the symptoms are relatively severe but do not involve a total block of speech activity. (3) Subtle, Slight Aphasia involves cases wherein the disturbance is not always evident at all times. It may appear most strongly only during instances of emotional disturbance or fatigue ( Luria, 1970b, pp. 34-35). Because initial trauma to the brain often results in a temporary disturbance of speech activity, Luria is emphatic that judgments with respect to symptoms and severity should be made only during the residual stage, which is the period 2 to 5 months after the trauma.
In addition to grouping by severity, Luria follows the classification schema that was encountered in earlier articles: acoustic aphasia, afferent motor aphasia, efferent motor aphasia, frontal dynamic aphasia, and semantic aphasia.
Of particular interest with respect to the focus of this book is a section wherein Luria, with his usual attention to philosophical bases of research, precedes his presentation of specific types of aphasia with a consideration of "The Structure of Speech Activity." In this brief section, he presents his explanation of when speech phylogenetically became intrinsically linked to thought:
The isolated words of which verbal speech consisted in its earliest stages of development were capable of reflecting separate signs or primitive concepts, but they could not express even elementary thoughts. The meaning of a word shifted depending upon the situation and was nonexistent outside certain situations. Whereas words possessed a nominative function from the beginning, the predicative function derived only from the concrete setting in which they were uttered. A decisive change occurred when speech went from consisting of individual words to consisting of elementary grammatical sentences, when instead of a single word there arose a pair or group of words related to one another, i.e., when the first "syntax" appeared.
The revolution which occurred at this phase in the development of language was truly phenomenal . . . . verbal speech became capable not only of designating an object, but also of formulating a thought. Verbal speech was still bound up with other forms of expression such as gesture and intonation, but with the development of written language thought came to be expressed altogether by means of language and speech became fully capable of performing the predicative function. Speech became an independent system of codes. ( Luria, 1970b, p. 83)
Because the development and structure of speech is so complex, Luria maintains that any consideration of its disturbance cannot be simplified and considered to be merely
disturbances or the speech images of words or . . . the inability to pronounce words. The basic forms of speech disturbances must result from defects in the systems of connections which are concealed behind the word on one hand and in the disintegration of the predicative function of speech on the other. The whole sense of verbal statements resides in this function. Similarly, the cerebral mechanisms which underlie speech processes cannot be at-

Speech and Orienting response

Frontal Lobes and the Regulation of Arousal Processes" ( 1970) was co-authored with E. D. Khomskaya, and appeared in Attention: Contemporary Theory and Analysis. The article reports on the results of studies conducted with normal subjects and brain lesion patients in an effort to ascertain the role of the frontal lobes in the regulation of arousal processes or the orienting reflex. The orienting reflex is
a complex functional system which includes a series of somatic, sensory, vegetative, electrocephalographic, and other components. While having a certain autonomy, all components of the orienting reflex obey common laws: they appear with the presentation of stimuli which are new for the organism; they have a nonspecific character, i.e., they do not depend on the modality of the stimulus; they disappear in proportion to repetition; and reappear with any changes in the experimental situation. Another no less important factor that elicits orienting reactions, is the significance or signal meaning of the stimuli. ( Luria & Khomskaya, 1970, pp. 303-304)
The authors demonstrate that, anatomically and neurologically, a number of connections exist between the frontal lobes and those structures of the limbic system and brain stem that are responsible for states of wakefulness, arousal, and the orienting reflex. The latter structures provide the efferent link in the system while the afferent link seems to be located at the cortical level.
The most significant finding of the experiments for our purposes is the fact that in humans one can regulate the orienting reflex by means of speech, which does physiologically modify the same:
If, by means of speech, stimuli are given signal meaning, a series of changes in the system of the orienting reflex occurs, namely: extinguished orienting reactions reappear and become more intensive (their latent period is shortened, their strength and duration is increased), they do not extinguish any more, and they arise for a wider range of intensities (as a result of the lowering of the threshold of sensation and the elevation of the threshold of the defense reaction). In this situation, the orienting reactions become more discriminating. They are not responsive to any outside nonsignal stimuli. Similar changes in the system of the orienting reflex occurring with the introduction of verbal instructions are observed in all normal subjects who are in an awake state (grownups and children, beginning from 8-10 years of age). ( Luria & Khomskaya, 1970, p. 304)
The authors indicate that this regulation of the orienting reflex by means of speech is such an essential characteristic of human mental functioning that it "may serve as an important indicator of the normally functioning brain" ( Luria & Khomskaya, 1970, p. 305). The balance of the article recounts their endeavors to test this hypothesis, and their conclusion


Reviewing his research findings on the role of the frontal lobes in the activation processes, verbally programmed behavior, and problem solving activity, Luria notes that "Each human activity starts from definite intention, directed at a definite goal, and is regulated by a definite program which demands that a constant state of cortical tone be maintained" ( Luria, 1973a, p. 5). It is his conclusion that the frontal lobes have vital roles in the state of activation that arises when the brain has some task to perform.
In addition, the frontal lobes are vital in the process whereby the orienting reflex is intensified and stabilized as a result of verbal instruction, so Luria concludes that they have a vital role in specifically human forms of attention.

Cole: implications of functional systems on lesions

The first is that the cerebral component of any functional cortical system results from the interaction of a constellation of cerebral areas. Thus, a functional system is localizable in the sense that damage to any one of the areas involved destroys the functional system. Defects will appear in the psychological activities dependent upon this functional cortical system. Second, a given psychological activity, for example, reading, may be performed in different ways, that is, by different functional cortical systems. Thus, a psychological activity is not localizable in the sense that if damage to a structure destroys a functional cortical system upon which reading is based another functional system cannot be developed which would carry out that same activity of reading. Third, the most important adaptive functions that man possesses, such as abstraction, computation, and speech itself, depend upon functional cortical systems which are acquired rather than innate. The fourth major assumption is that the most important determinant of functional cortical systems in man is the organization of the social environment. ( Cole & Maltzman, 1969, p. 278)

adynamic aphasia , inner speech and rehab

"The Mechanism of 'Dynamic Aphasia'" ( 1968) was co-authored with L. S. Tsvetkova, and postulates that dynamic aphasia is a disturbance of "inner speech with its predicative function, which takes place in forming the structure or scheme of a sentence, . . ." ( Luria & Tsvetkova, 1968, p. 297). The article reports on their attempts to test this by experiments with 15 patients with dynamic aphasia and 15 normal subjects. The aphasia patients exhibited more difficulty in naming actions than in naming objects, and could not form sentences out of all the separate words necessary to do so. Normal patients had no difficulty with either task. External cues (such as pieces of paper) assisted the subjects in compensating for this loss of the "linear scheme of the phrase . . ." ( Luria & Tsvetkova, 1968, p.
"Frontal Lobe Syndromes" ( Luria, 1969a) constitutes a chapter in the Handbook of Clinical Neurology, Vol. 2, edited by P. J. Vinken and G. W. Bruyn , and provides a comprehensive consideration of the morphology and functioning of the frontal lobes.
Luria provides such basic information as the fact that the frontal lobes are the youngest portion of the cerebral hemispheres evolutionarily; comprise approximately one third of the total human cerebral cortex; and consist of three main regions: the motor area, the premotor area, and the prefrontal area together with the mediobasal aspects of the frontal region. The complexity of this area of the brain is evidenced by the fact that Layer III of the neocortex in Area 6 of the premotor area contains approximately 207 million pyramidal cells. Because each cell may have 2-3,000 synapses, the reader can gain some appreciation of the multiplicity of connections with other areas of the brain of which the frontal lobes are capable.
The most complex zones of the frontal lobes do not complete their physical development until the individual is 7-12 years of age; and the integrative tertiary zones of cortical development are found in the prefrontal region.
A detailed analysis is presented of the morphological, physiological, and clinical data on each of the three regions of the frontal lobes. Of particular interest are the disturbances of higher mental processes and speech that result from lesions in these regions. These have been presented in the reviews of other articles on the frontal lobe syndrome, but this chapter presents the same in more detail and states:
Analysis of these disturbances shows that they are based on difficulty in performing complex movements generalized in time. There is difficulty in denervating one link and moving on smoothly to the next. This disturbance of "kinetic melodies" is the fundamental symptom of a premotor lesion . . . . ( Luria, 1969a, p. 731)
With respect to how frontal lobe lesions affect speech, Luria states that
If the lesion is situated in the inferior portions of the premotor area of the dominant (left) hemisphere, phenomena similar to the disturbances of kinetic melodies described above may also appear in speech and verbal thinking. The patients of this group begin to have difficulty in fluent speech, their speech becomes interrupted, and difficulties arise in the transition from one element of articulation to another. Similar phenomena of the loss of smoothness (and sometimes of perseveration) may also appear in writing. ( Luria, 1969a, p. 733)
If the symptoms are severe, one has a case of efferent (or kinetic) motor aphasia.
The symptoms of frontal lobe lesions vary somewhat, of course, depending upon the location of the lesion; however, Luria indicates that there are two main symptoms that occur
in almost every massive lesion of the prefrontal regions. The first of these symptoms was a disturbance of the complex forms of active purposive behavior, and the second a disturbance of the critical attitude towards the patient's own defects. Both of these components of the "frontal syndrome" were observed as a rule in all massive lesions of the frontal lobes, although they varied in lesions of the convex and basal portions of the frontal region, and differed depending on the severity of the lesion . . . . ( Luria, 1969a, p. 738)
When such characteristics arise from a lesion of the left prefrontal region, they are manifested in speech activity and verbal thinking and distinguish the aphasia Luria labels dynamic aphasia.
"

Vocate: more on inner speech

External speech includes the spoken language first of others in the child's social environment and thus is the stage that includes the initial sociocultural origins of spoken language. The child's external speech is initially imitative and then evolves into egocentric speech, which, according to Luria, serves a special function in aiding the child in organizing his behavior, and is characterized by its "coding for self" nature. Such speech is gradually internalized, and becomes internal or inner speech. However, in the process of internalization, it is modified somewhat so that its most distinctive feature becomes its predicative nature and it becomes characterized by its ellipsis, synthesis of meaning, and silence. A. R. Luria presumes a familiarity by his reader with these basic developmental stages,

Vocate: written and inner speech

the functional and structural features of written speech . . . have . . . one important aspect; they inevitably lead to a considerable development of inner speech. Delaying the direct revelation of speech connections, inhibiting them and showing increased requirements for the preliminary speech act not being revealed at once by training, written speech produces such a rich development of inner speech as could not have a place in the earlier phases of development. Therefore, neuropathologists are not working at random when, desiring to investigate the possibilities of inner speech, they turn to the nature of the written speech of their patients. ( Luria, 1961d, p. 738)
De

Vocate Luria on consciousness

"'Brain and Conscious Experience'": A Critical Notice from the U.S.S.R. of the Symposium Edited by J. C. Eccles ( 1966)" ( 1967a) is Luria's review for the British Journal of Psychology of the transcript of an international symposium on brain/consciousness called by the Vatican Academy of Sciences and organized by its President, Sir John Eccles.
Luria chides the majority of the prominent participants for their archaic philosophical orientations to the brain/consciousness question, and notes that
In spite of the fact that the definitions of consciousness given by the participants were varied, not one of them understood consciousness as the reflexion of objective reality, as "conscious being" or as complex activity which has a semantic and systematic structure. ( Luria, 1967a, p. 469)
Rather, according to Luria, the participants were roughly divided into two groups: one group, exemplified by Penfield, sought the material basis for consciousness inside the brain and anticipated discovery of the formations in neuronal structure that give rise to this phenomenon; the other group, typified by MacKay, rejected any study of neuronal structure and called for the study of logical systems concerned with the processing of information, which are somehow the basis for conscious experience.
After reviewing the new directions in brain research represented at the symposium, Luria goes on to note that the central problem of the conference was "the question of the role played by the non-specific system of the brain stem in providing an active and waking state for the cerebral hemispheres . . . ." ( Luria, 1967a, p. 471). This problem arises from the knowledge that the non-specific reticular system of the brain stem interacts with the specific or cortical formations of the brain--stimulating and receiving stimulation.

Vocate: More on PD rehab

The dominance of the cortical level over the sub-cortical level is adduced by Luria's research with Parkinson's disease patients ( 1959b, 1960b, 1961a, 1967d), which demonstrated that it is possible to transfer the control of defective involuntary (sub-cortical) motor behaviors to the voluntary (cortical) motor areas so that the subject can still perform the desired action because the pathology has left the cortical areas intact.
In Parkinson's disease patients:
The injured subcortical apparatus excites repeated tonic responses, and the pathologically perseverating tension of all muscles is an obstacle to the execution of the instruction. It is easy to imagine such a difficulty in carrying out a voluntary movement if one briefly tenses all the muscles of one hand and then tries to move it without relaxing the tension. ( Luria, 1959b, p. 455)
However, if the origin of the motor act is shifted from the automatic movement realm governed by the sub-cortical motor apparatus to the conscious movement domain of the cortical motor areas, the patient is able to carry out the required movements. This may be accomplished by
attaching a symbolic function to his movements. He is asked to reply to the experimenter's questions by beating out the necessary numbers with his finger. If we then ask him, "How many wheels on a car?" or "How many points on a compass?" we see that the same patient who had failed in the previous experiment and could not automatically strike the table with his fingers even two or three times, easily begins to do so, switching his movements into his speech system and subordinating them to the complex dynamic constellation of cortical connections. ( Luria, 1959b, p. 455)
Similarly, the Parkinson's disease patient who is unable to walk more than one or two steps will find that his difficulties
in successive automatic movements may be compensated for temporarily if they are transferred to the cortical level, and if the continuous movement is superseded by a cycle of isolated responses to individual stimuli. Such a patient cannot take several steps on a smooth floor but can easily cross several lines marked on the floor or several objects placed on the floor. ( Luria, 1967d, p. 417)
Such mechanisms force the control of the normally automatic components of walking to the conscious, voluntary control of the cortical level by separating them into individual responses to individual stimuli, thus requiring cortical level processing.

Vocate: What language means (Luria)

The function of generalisation is the main function of human speech, without which mastery of the experience of preceding generations would be impossible. But it would be wrong to think that this is the only basic function of speech. Language is not only a means of generalisation; it is at the same time the source of thought.
When the child masters language he gains the potentiality to organise anew his perception, his memory; he masters more complex forms of reflection of objects in the external world; he gains the capacity to draw conclusions from his observations, to make deductions, the potentiality of thinking.
When the child names something, pronouncing, for example, "that is a steam engine," he is at the same time analysing with the aid of means developed through many generations . . . . Saying the word "steam engine" (paravoz) he begins to understand that in the movement of the machine named steam (par) plays a role and that it moves other objects. In mastering words and using them the child analyses and synthesises the phenomena of the external world, using not only his personal experience but the experience of mankind. He classifies objects, he begins to perceive them differently and with this to remember them differently.
But the speech mastered by the child does not consist of single words; it consists of complex grammatical combinations, of whole expressions. These expressions allow not only for the analysis and synthesis of perception, but also the connection of things with actions, and still more the posing of things in certain relations with each other. Acquiring forms of developed, connected, speech the child acquires the potentiality not only to form concepts but also to draw conclusions from accepted assumptions, to master logical connections, to cognise laws, far surpassing the boundaries of direct, personal experience; in sum, he masters science, gains the potentiality to foresee and foretell phenomena, which he could not do by merely witnessing them.
What has been said up to now does not fully cover the role of language, the role of speech, in the formation of man's mental processes. Speech activity besides being a means of generalising and the source of thought is also a means of regulating behaviour. ( Luria, 1963c, pp. 85-86)

Vocate: Luria on PD, cerebroasthenia, oligophrenia

Evidence is then presented on how the directive function of speech is affected in three types of neural disorders: Parkinson's disease, cerebroasthenic syndrome, and oligophrenic children.
The sub-cortical area is damaged in Parkinson's disease, but the cortical motor centers are fully intact. The sub-cortical motor centers' damage causes muscles to exhibit a pathological perseverating tension soon after any initial movement, and thus involuntary action becomes impossible. However, movement can be tied to cortical control by requesting the patient to tap his finger once each time the interviewer says, "Now," and thereby controlled for longer periods. In addition, linking the movement more closely with the patient's speech system by imbuing it with a symbolic function also resulted in the patient demonstrating no difficulty in controlling his execution of movement (finger taps) in response to "How many wheels on a car?" or similar questions.
In cases of cerebroasthenic syndrome, the cortex exhibits a stimulational weakness because neural strength is weakened and equilibrium of the neural processes is impaired. In other words, the cortex itself is in a pathological state, rather than just the sub-cortical processes, as in Parkinson's disease. However, Luria found that the verbal response of a child with this syndrome suffered less than his motor processes. Khomskaya's experiments are presented as evidence that it is the inhibitory or semantic
aspect of speech that is still capable of directing the child's behavior because nonsense syllables or irrelevant utterances had no influence on the child's motor reactions.
The speech system is more drastically affected in cases of oligophrenia. This is a form of deep mental retardation that results from intrauterine or very early childhood damage to the brain, and:
It is particularly characteristic of these children that the dynamics of neural processes underlying speech activity are in their case impaired not less, but more than the dynamics of neural processes which are materialized in simpler sensorimotor reactions. ( Luria, 1959b, p. 458)

Vocate: Luria Developmental and Dissolutiona;

During the approximately 20 years before his next English publication on the verbal regulation of behavior, Luria expanded and refined his concept of speech being the mechanism whereby behavior is directed. A twopart article appeared in Word ( 1959) entitled "The Directive Function of Speech in Development and Dissolution." As might be anticipated, the two parts reflect his two fundamental strategies: Part I presents the developmental view, and Part II is concerned with the pathological view.
In "Part I: Development of the Directive Function of Speech in Early Childhood" ( 1959a), Luria outlines the stages by which verbal signals gradually supplant the directive influence of the immediate visual signal for the child. Speech has both an excitatory and an inhibitory function; and developmentally, the excitatory precedes the inhibitory. Due to the insufficient mobility of the 3-31/2 year-old child's neurodynamics, the excitatory is still strongest so that if one alternates excitatory and inhibitory

stimuli to a child of that age, the excitatory will come to dominate and motor perseveration will result.
The impulsive or excitatory aspect of speech continues to dominate until approximately 4-41/2 years. Then,
as soon as the directive role passes to the semantic aspect of speech and that aspect becomes dominant, external speech becomes superfluous. The directive role is taken over by those inner connections which lie behind the word, and they now begin to display their selective effect in directing the further motor responses of the child. ( Luria, 1959a, p. 351)
In "Part II: Dissolution of the Regulative Function of Speech in Pathological States of the Brain" ( 1959b), Luria maintains that for external speech to influence behavior, the subject must not only hear the verbal instruction but also:
A number of further conditions must be fulfilled; important among them is the maintenance of the strength, the equilibrium,

Vocate: Characteristics of speech, Luria

General Characteristics--Spoken Language
1.
Spoken language is a higher mental process, and embodies all the characteristics of such processes:
a.
It has sociocultural origins.
b.
It is a complex functional system built on a functional base of the more elementary sensory systems of the brain, and is capable of controlling such systems.
c.
It arises from a material base that is a "complex functional system of conjointly working cortical zones . . ." ( Luria, 1966b, p. 35).
d.
It evolves through a pattern of developmental stages rather than existing as a static, innate quality of the brain.
e.
It has a mediated structure in that it incorporates auxiliary stimuli ("stimuli artificially introduced into the situation") ( Vygotsky, 1966, p. 24), which are usually produced by the individual himself.
f.
It is distinguished by the fact that the speech system is always a factor in its formation.
g.
It is originally both conscious and voluntary in nature rather than being passive and merely reflexive.


1.
Spoken language is the most readily influenced of all the higher mental processes.
2.
Spoken language can be either excitatory or inhibitory as a stimulus. Developmentally, the excitatory or impulsive aspect precedes the inhibitory or semantic aspect of spoken language.
3.
Functionally, spoken language has three dimensions:
a.
It is a form of social communication.
b.
It is a tool for intellectual activity.
c.
It is a method of organizing or regulating mental processes.
4.
Spoken language's process can be subdivided into two processes: impressive speech or decoding, and expressive speech or encoding.
5.
Spoken language has both a paradigmatic (vertical) and a syntagmatic (horizontal) structure.
6.
Spoken language's semantic component includes both "sense" and "meaning."
7.
Spoken language is sympractic in nature.
As previously noted, the term spoken language is synonymous with Luria's term speech, and is used to reflect the inclusion of psychological activities as well as the code of language in this theoretical unit. Other terminology used above in outlining the general characteristics of spoken language is clarified during discussions of these characteristics in the ensuing chapters concerning various topical areas of Luria's work.

Vocate: Luria on development of language

supported by extralinguistic (sympractic) aids--knowledge of the situation, facial expression, gestures . . . information can be transmitted by extralinguistic aids, and incomplete expansion, ellipsis, the participation of intonation, and so on, can exist. ( Luria, 1976a, pp. 36-37)
Although this difference may be observed in the successive developmental states of childhood language acquisition, it originates in the historical development of language:
It is an important fact that in the early period of history language did not include all the constructions necessary to express a complex communication. Language itself was an inseparable part of practical activity, it had a relatively simple structure, and the adequate understanding of these relatively simple constructions requires the participation of a "sympractic context"; for this reason, primitive languages could remain unknown without knowledge of the concrete situation in which a particular communication was used, of the gestures that accompanied it, of the intonation with which it was uttered, and so on. That is why, as the famous ethnologist Malinowski ( 1930) pointed out, the expressions used by many peoples standing at a primitive level of social development can be understood only if the concrete situation is known and if their gestures are observed . . . .
Only in the course of its long historical development has language gradually developed its own "synsemantic" forms of expression of relations, and so, as Buhler ( 1934) stated, it has become "a system that includes in itself all the means of expressiveness." Thus the whole evolution of language can with full justification be represented as the path of liberation from dependence on the sympractic context and of gradual formulation of methods increasing the role of the linguistic (grammatically constructed) synsemantic context proper. ( Luria, 1976a, p. 156)
To say

Vocate Luria on oral v written speech

Careful analysis by Vygotskii ( 1956) and El'konin ( 1954) indicated that written speech represents an entirely new psychological phenomenon, different from oral speech.
Oral speech forms during immediately practical intercourse and its component elements long remain insufficiently conscious, unseparated by the child from general speech activity ( Morozova, 1948; Karpova, 1955). Written speech follows exactly the opposite course. It is always the product of special training, which presupposes the separation of individual words from the flow of living speech and individual sounds from the living word. It also involves abstraction from individual phonations of sounds and the conversion of sounds into stable phonemes. This process of analysis, described in the Soviet literature by Luria ( 1950), Nazarova ( 1952), and others is a necessary technical premise for the act of writing, which from the very beginning requires conscious effort.
Oral speech always originates in close connection with immediate experience, as, for example, in sympractical and situational activity. It relies on intonation and gesture and usually becomes intelligible only if the general setting of the conversation is considered. It permits extensive abbreviation. For a prolonged period it continues to bear traces of the period when the subject was contained in speech and the predicate in a gesture, a tone, or in the immediate situation. Written speech . . . is deprived of this sympractical context, and therefore it must be more detailed, contextual, or, to use Buhler's term, synsemantic. Written speech like a work of art, to paraphrase Leonardo da Vinci, should contain within itself all means of expressiveness and in no way depend on the concrete environment. ( Luria, 1969c, pp. 141142)

Vocate: Luria on speech v language

Spoken Language
The speech system that reorganizes mental activity to permit the conscious voluntary functioning of higher mental processes is very complex and includes both speech and language. These components are often studied in isolation from each other; yet, as Luria indicates, the origins of speech and language are intertwined:
Under the conditions of primitive society language began to develop as a means of communication; there, in accordance with laws not yet known to us, verbal speech appeared. In the development of verbal speech words gradually became separated from work activities and from signalling gestures; words began to abstract and at the same time to generalize various characteristics of objects. They thus achieved designating and at the same time generalizing-systematizing functions.
In later social history language attained its complex, phonetic, lexical, and grammatical structure and gradually became the objective system of codes which is well known to contemporary linguistics. ( Luria, 1970b, pp. 20-21)
This complexity, which developed gradually, necessitates the separation of "verbal speech" into its speech and language components before one can hope for a clear understanding of the phenomenon:
It was de Saussure who was responsible for the clear differentiation between the concept of language (langue), as an objective system of sounds formed in the course of history, and the concept of speech (parole), by which he understood the process of transmission of information with the aid of the language system . . . . ( Luria, 1976a, p. 10)
The term language is used throughout the book to refer to an "objective system of codes" as Luria defined it; or more precisely to "The culturally determined syntactic systematization of signs and/or symbols" ( Dance, 1979, p. 2). This conceptual definition will assist in understanding the theoretical unit of spoken language although it is not sufficient to delineate the same.

Notes on Donna Vocate

1. Vygotsky's view was that language arose not in the psychic nor the physical but in social history

2. Every function in the child's cultural development appears twice: first, on the social level, and later, on the individual level; first, between people (interpsychological), and then inside the child (intrapsychological). This applies equally to voluntary attention, to logical memory, and to the formation of concepts. All higher functions originate as actual relations between human individuals. ( Vygotsky, 1978, p. 57)

3. There is reason to believe that voluntary activity, more than highly developed intellect, distinguishes humans from the animals which stand closest to them. ( Vygotsky, 1978, p. 37)

4.General Characteristics--Higher Mental Processes
1.
Higher mental processes have sociocultural origins. Consequently, such processes transcend the individual's experience and reflect the cultural level of the social environment of the individual.
2.
Higher mental processes are complex functional systems built on a functional base of the more elementary sensory systems of the brain, and capable of controlling such systems.
3.
Higher mental processes arise from a material base that is a "complex functional system of conjointly working cortical zones . . ." ( Luria, 1966b, p. 35).
4.
Higher mental processes evolve through a pattern of developmental stages rather than existing as static, innate qualities of the brain.
5.
Higher mental processes have a mediated structure in that they incorporate auxiliary stimuli ("stimuli artificially introduced into the situation" ( Vygotsky, 1966, p. 24), which are usually produced by the individual himself.
6.
Higher mental processes are distinguished by the fact that the speech system is always a factor in their formation.
7.
Higher mental processes are originally both conscious and voluntary in nature rather than being passive and merely reflexive.

Frontal alternating tests Luria

tap two beats, then switch to three beats

alternating square wave and triangle wave in a connected line

fist palm edge

draw 3 elements is succession to verbal instruction: circle, cross and minus sign. Maintain elements and then have a new command with a switched order of elements

Learning poetry by heart

VISUAL presentation of v oral of a series of letters, numbers, or words or figures

Testing spatial (simultaneous) synthesis and successive synthesis

Spatial= figure copying, left-right, hand postures, mental rotation
Successive- tapping rhythms, ordering 4 words or symbols, or numbers

Balint's inability to do simultaneous analysis does successive

Sorkina and Homskaya (1960) found such patients could differentiate red and green, then white and yellow, but then if presented with all 4 then respond haphazardly to signals.

Tactile loss of simultaenous synthesis (agnosia) unable to synthesize a whole pattern is described by Delay (1935) and Denny Brown (1952) and called amorphosynthesis.

Other spatial synthesis tests that may be done incorrectly include drawing the direction of an arrow, distinguish symmetrical figures, know which way to draw a line in a geometrical figure, draw letters, production of mirror writing.

Quotes interesting from, about, re Luria and colleagues

Most taken from Human Brain and Psychological Processes

Gall was " a celebrated anatomist but an equally great dreamer. On a basis of incomplete observations and speculative conclusions he considered that faculties such as love of children, respect for parents, a sense of mental elevation or a feeling of self could be localized in circumscribed areas of the cerebral cortex" p.4

JC Eccles (1951) At what point does the mind "enter the brain" and begin to "interact with it"

"there is no evidence for isolated cerebral centers" Luria p.13

"A function which was initially shared by two people and bore the character of communication between them gradually crystallized and became a means of organization of the mental life of man himself" Vygotsky 1960 cf. p23

"The human brain does not contain any ready made mental faculties. The cerebral cortex is " the organ capable of making new functional organs." Le'ontiev 1961 p. 38

Deutsch (1953) summarized by Pribham (1960) cf p. 33 "Destruction or constant electrical stimulation of the hippocampus in animals leads to considerable disturbance of balanced behavior. Animals are unable to perceive signals giving information concerning its own erroneous reactions so that these are no longer corrected. The normal regulation of behavior is thus disturbed." Aden(1959) and Holmes and Adey (1960) did experiments of ele stimof hiipocampus showing same thing.

Sechenov-- idea that visual scanning was as important to visual perception as was reflection in retina

Yarbuss (1956) An object falling on a single point of retina ceased to be visualized after 2-3 seconds and to be kept as an image for longer than that the eye has to make small movements.

Analysis of Chinese writing bypasses phonology since writing incorporates idea of words rather than the sounds. Writing in Russian has many more mistakes if child is prevented from performing inner or silent speech while writing (Nazarova, 1952).

Structure of writing also changes during stages of learning to write versus already knowing how and doing it as an overlearned process.

Sechenov--1878 Mental processes fall into 2 categories: integration of elements in simultaenous groups, and placing elements in successive series. Simultaneous groups are essential for creating an adequate image of the outside world is generally associated with the visual, kinetic and vestibular apparatuses, responsible for the orientation of the body in space. Conversely, successive stimuli is primarily associated with the motor system on the one hand, and the acoustic system on the other.

Chronologic localization in development requires perfect concrete reflection of outside world (Perception = first signal) in order for speech (verbal semantics=second signal) to develop normally.

Vygotsky: In early development,the direction of dependence of psychological activities is bottom to top (primary simple processes are the basis for more complex ones) but in late stages its top to bottom . For example, a hearing deficit in a child will result in an inability to speak whereas in an adult it will not. Moreover, a lesion of the occipital cortex in a child will not give rise to optic agnosia alone or allowed the formation of other mental activity undisturbed.

A lesion of the brain at different stages of ontogenesis may have completely different consequences. Vygotsky's principle restated p. 62 " In a lesion of a particular 'center' in early childhood, the corresponding 'higher center' in closest relationship to it is secondarily affected, whereas in the case of a similar lesion in an adult it is the dependent lower 'center' that is primarily affected and the specific relationship between the centers is laid down during development. "The theory of constant specific functions of each organ is unsound " (Vygotsky, 1960 p 381.

"The concept (of localization) leads to pessimistic conclusions that the restoration of functions is completely impossible " p. 63. However these conclusions are contrary to the facts repeatedly observed.

Inhibition of wider area is Monakow's diaschisis. Luria interpreted diaschisis as meaning inhibition of the function of neurons situated within the focus and close to it, disturbing their synaptic conduction, and as a result the morphologically intact nerve cells become inactive. Pavlov interpreted the physiologic basis in terms of the theory in terms of limiting protective inhibition, and by Soviet neurologists in investigations of functional asynapsia (Graschchenkov 1946, 1948).

Those 2 studies above, plus others (Luria 1948, Perel'man 1946, Eidinova and Vinarskaya (1959) showed beneficial effects of prostigmine, eserine and galanthamine.

Lashley (1960) regarded speech as one of the most obvious examples of serially organized cerebral activity. Chomsky used Markov chains and mathematical principles to analyze serial or syntactic structures.

History of Neuropsychology

Benton AR. Neuropsychology Past present and future

Old terms

psychoneurology Bekhterev

brain pathology Kleist

enteroid processes-- old term for gyri of brain till 1820'a



Nemesius-- sensation and perception in anterior ventricles, thinking and reasoning in third ventricle and memory in fourth v (400 AD).

Antonio Guanerio (15th century) - anomia is due to phlegm in fourth v.



Thomas Willis sensation is in corpus striatum , perceptual integration in callosum and memory is in cortex.

Peyronie-- callosum is seat of intellect

Jackson 1878-- to locate the lesions which destroys speech and to locate speech are two different things

Head 1926 =the processes which underlie an act of speech run through the nervous system like a prairie fire from bush to bush.



Brissaud 1897 compared aphasie d'intonation with aphasie d'articulation

Goldstein- related amnesic and conduction aphasia to "abstract attitude"

Kleist- differentiated speech sound deafness and speech meaning deafness (1923-4)



Teuber responsible for term neuropsychology using it in 1948.

Luria on Thinking

c13 p. 323 Working Brain

Luria engages in historic analysis of constructs and concludes that thinking, ought to be considered as a complex act with component parts, and then it can be considered. Word meaning, the basis of ideas, develops in childhood and gradually becomes abstracted.

Luria states "psychologists are unanimous" that thinking arises when a subject arises for which he has no ready made inborn or habitual solution. Then, thought requires, successively, the restraining of impulsive responses, investigation of the conditions of the problem, analysis of its components, recognition of their most essential features and correlations with each other. Finally is the selection of one from alternative and the creation of a scheme for the performance of a task, or strategy formation. Finally is the choice of methods and operations to put the scheme into effect, the tactics of the solution. The last step is actually the comparison of the results with the original conditions of the task.