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B E H A V I O R A LS T U D I E SO F A P H A S I A :
M E T H O D SO F I N V E S T I G A T I O NAND ANALYSIS*
INTRODUCTION
Apuasla, despiteits clinical prominenceand vast literature,has achievedonly rudimentary
agreementon methodsfor examiningpatientsand classifyingtheir deficits. One sourceof
confusion,stressedby JecxsoN!], has beenthe uncriticalmixing of psychologicand phsio-
logic or anatomic concepts. This distinction has, unfortunately, led some workers to advo-
cate the primacy of one or the other method of classification. BnelN [2] has provided an
excellenthistory of the controversy.
Although the psychology-physiologydistinction is valid, the problem is not to determine
which is primary. Observedaphasicdeficitsare behavioral, but they result from anatomical
lesionsand derangedphysiology. Correlations of lesionswith behavioral deficits, however,
will be exercisesin futility if either set of observationsis improperly controlled or has no
consistent classificatory schemeof its own. The behavioral examination and classification
must be at least as rigorous as the physiologic and anatomic if the correlation is to be
meaningful.
This paper describesbehavioral techniquesfor examining, analyzing and classifying
certain aphasic deficits, illustrating the methods through a relatively comprehensiveexa-
rnination of one patient. Two basic behavioral concepts,reinforcement and stimulus
control, underlie the methodology.
Reinforcement
A powerful ernpiricalprincipleis that consequences governbehavior. Behavioris likely
to recur if it producesreinforcingconsequenccs (for example,food); behavior that con-
l19
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P. Morrn ancl.1.l-r,rcr,slrrr
Stimulus control
A responseusuallyproducesreinforcementonly when a particular stimulus is present.
Receptororientation and the lessclearly definedprocessesof selectiveattention determine
which elementsof complex stimuli exert behavioralcontrol. The role of selectiveattention
in behavioral deficit will be clarified in this report.
The patient's experiencewith the stimulus-responserelations being studied, physical
and social featuresof the test environment,and the instructionshe receiveswill influence
his performancethroughout the examination. Such factors modulate stimulus control [7].
Automated test proceduresand immediatereinforcementof the patient's correct responses
give him reliable nonverbal instruction about the adequacyof his performance,and help
circumventhis particular social and educationalbackground.
Since a modulating factor controls many stimulus-responserelations, a diseasethat
changesthe influenceof such factors will causewidespreaddeficits in stimulus control.
Similarly,if reinforcementis no longer effective,deficitswill be widespread.To distinguish
a generalstimulus-cor.rtrol deficitfrorn a breakdownof the response-reinforcementrelation,
the examinermust demonstratethat the reinforcer he is using is still effective. Also, the
generalstimulus*controldeficit must be classifiedseparatelyfrom breakdownsconfined to
restricted stimulus-responserelations.
Stimulus-responserelations have arrother critical characteristic: a single stimulus
controls many responses;a single responseis controlled by many stimuli. Diseaseneed
not break down all relationsin which a particular stimulus or responseparticipates. For
example, S may be a printed word that controls oral reading (S-Rr), copying (S-Rz),
and pointing to a picture (S-Rt. A cerebrallesionthat destroysS-Rr but leavesthe other
AND ANALYSIS lzl
IIEIIAVTORAL SfUl)tES OI APHASIA: Mt'l'tlODS OF INVIS-TIGATION
METHODS
roomandfaceda squarematrix-ofninetranslucent windows'each
Thepatientsatin a sound-resistant matching'
Jquur.. H" performedfour typesof tasks: simultineous delayed
matching-to-sample,
Z in"t es . named in writing
naming. The to
stimuli be named
matched, or
orally,
oJ na-lng, andwritien<oip.Lt"Ol
werepresented throughvision,hearing,or touch'
Si multaneousmatt hi ng-to-sample
was projected onto the
visual-visualmatching (visual sampleantl visual choices). A sample stimulus
window, stimuli (choices)
center window of tt" mui.i* 1Flg. r-A). When the patient pressedthe center
correspondedto
ttre outer windows (-pig.t-n). He was then to pressthe outer window that
"pp."..J." lf he chose correctly,'chimes rang.and a nickel was automatically delivered. Incorrectresponses
ifiir".pf
darkened; 1.5 sec
p.oOu..O".neither chimesno. niik.l. Immediatelyafter each choicethe windows were
later a new sampleaPPeared'
Auditory-visualmatching(auditorysantpleandvisualchoices). Auditorysampleswerewords:thespoken
used as visual stimuli'
equivalentsof the pictures,'.irf"it, nurnbers,objects,letters,and words that were
onceevery2 seconds',-The
A mastertape read ttre woid onto a tape loop wirich repeatedit approximately.
patien-t'stask was: pressthe blank
centerwindow, although illuminated,containedno visual sample' The
center window to producevisual choices; then, press the outer window that had a visual stimulus corres-
choicesneither'
ponding to the auditory sample. Correct choicesproducedchimesand nickel; incorrect
1'5 sec later a new auditory
After a choice,repetitionoi the auditory sampleceaied,windowsdarkened,and
samplebeganthe next trial.
small common objects,
Tactile-visualmatching(tactile sampleantl visual choices).Tactile sampleswere
in. t'ign; upper-case, 2 in. hieh), or plasticdigits (2 in' high)' By placing his
plasticlettersllower-case,i.)l
being able to seethem.
tand into a box belowtt *inao* --utii*iir. patientcould feelthe sampleswithout
The centerwindow was dark, " but visualchoicls wereexposedwhile thapatient palpatedthe sample. After
withdrawn and a new one
he presseda visualchoice,pilducing chimesand nickelif correct,the samplewas
inserted.
D eIayed matching'to-samPIc
the sample (Figs'
The sample disappearedbefore choicesappeared;the patient had to remember
e). li tne sa.ple *u, visual, the center-window darkened when the patient pressedit' Auditory
l-C, rt,
pressedthe blank center window
sampleshad to occur at least once and then ceasedwhen the patient
and pressedthe blank
Tactile sampleswereremovedas soonas the patientcompletedhis tactileexploration
centerwindow.
Choicesat first appearedimmediatelyupon disappearance of the-sample(zero-delay)'Each time the
patie;t chosecorrectly,a ionger delay was inierposedbetweenremoval of the next sampleand appearance
patient'saccuracyadjusted
ofchoices. Ifhe madeun..rJ., a shorterdelayintervenedon the next trial. The
122 M < l t t t ra n d . 1 .l , , rt c l s r r , H
S I M U L T A N E O U SM A T C H I N G
C ( D EL A Y ) E
D E L A Y E DM A T C H I N G
the time over which he had to rememberthe samplc,the dclay increasingor decreasingin 4-secsteps (ad-
justing delay).
No stimuli were testedin delayedmatchingunlessthe patient achievedat least?5 per cent correct on
simultaneousmatching. A delay test endedwhen he chosecorrectly after a 40-secdelay or completedthc
test set without passing40 seconds.
Oral nanting
The patient had simply to say aloud the name of the sample. Free to say as many namesas he wished,
he had to indicatewhen he wasfinished. The final namewastakenas his response.lfthe patientnamed the
samplecorrectly,the examinerpresseda button which soundedthe chimesand delivereda nickel. After
incorrectresponses,the only consequence was presentationof the next sample.
Written narning
The patient had to write or print the name of the sample. He had a new pieceof paperfor each trial;
previously-writtennameswerenevervisibleto him. If he wrote more than one, the first wasrecordedas his
responseunlesshe crossedit out. When the patient handecthe paper to the examiner,reinforcementand
samplechangingproceededas in oral naming.
Stimulus materials
Sampleand choicestimuliappearin Appcndix1. With rcpeatcdtcsts,a systen"ratic rotation through
f o t l r t o s i x e q u i v a l c n t s e t s o f e a c h t y p c p r c v e n t e d t h e p a t i c n t f r o m l e a r n i n g d i s p l a y c o n f i gi rur real et ivoannst,
displayfcaturcs,and sequences of choiccsor window positions,all of which would havepermiltedhim to
achievehigh scoreswithout observingthc samples.
Most setshad 20 trials;somchad 18. To conserve timc, a testendedaftertcn trialsif morc than scvcn
or lessthan three were correct. Number and sequenceof testsper session,examiner, ancl time betwcer.r
sessionsvaried. The final task of a sessionwas usuallyone which the patient normally did well, providing
a control for fatigue,bordeom,discouragement, or satiation. A poor scorewasreportedonly if a good per-
formancewas obtainedon a differenttask later in the session,or if the poor performancerecurredduring an
adequatelycontrolledsession.
Summaryof procedures
ln Fig. 2, items in boxesare observable,controllable,and measurable.Unboxed items are intervening
events,to be consideredlater. Samples,at the left, provideciinitial input to the patient in any of three mo-
dalities; vision, hearing,or touch; he processedsamplesaccordingto the demandsof eachtask. In simul-
taneousmatching(top line), pressingthe samplewindow exposeda secondset of input stimuli, the choices;
the final responsein the sequencewas to pressa choicewindow. Delayedmatching (secondline) had the
sameinitial inpr.rtand final output as simultaneousrnatching,but the delayintervenedbetweensamplepress
and appearanceof choices;choicesappearedwithout the sample. Naming and writing (lines3 and 4) had
AND ANALYSIS
OF INVI]STICA'TION
OF APTIASIA:METHODS
STUDII]S I23
I]F,IIAVIORAL
lq!;a7yg - . - . .S 7 s l 1 Y q 6 l ,
romplc atPCfr ol
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5vir. -T
IRTGRAMS
SINGLEI,EIIERS
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WRIIING
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| 3 5 . 7 9 t 1 1 3 1 5 1 7 1 9 2 1 2 3 2 5 2 7 2 9 3 31 . 5t 7 9 1 1 1 3 1 5 t ? 1 9 2 1 2253 27 29 3'l
WEXS WEEKS
Frc. 3. Test scores as a function of time; singleJetter and trigram materials. Week I was
actually the third week post stroke.
an
a visual letter without having seeuor written it before. Tactile-writingmay also be
identity task; a patient who can draw tactilesamples1nayGopy a tactile letter he has never
felt or written before.
B y c o n t r a s t ,t h e p a t i e n tc o u l d n o t d o n o n i d c n t i t yt a s k sb y i m i l a t i o n ,c o p y i n g ,o r f o r m
in this
equivalen"e,but only by virtue of learnednediating responses'Nonidentity tasks
study were: all auditory-visual matching, visual-naming,tactile-naming' and auditory-
writing; visual matching of words with pictures,words with colors, words with numbers,
a n d n u m b e r sw i t h d o t s .
We believethat delayed matching. even of identity tnaterials,is a nonidentity task'
In delayedmatching, sampleand choice are neveravailablefor simultaneousGomparison;
the
the patient nrust respondto the samplewith sorre behaviorthat permits him to bridge
delay. Two observationswould be consistentwith the interpretation of delayedmatching
task is
as a nonidentity task: a breakclownin the patient'sperformancewhen an identity
of improvenlent in
changedfrom simultaneous to delayedmatch ing ; different relative rates
simultaueousarrd delayednratching.
We shall now documentthe validity of the identity-nonidentitydistinctionby showing
that:
A. Within eachresponsecategoryidentity tasksimprovednrore rapidly than, or along
with nonidentity tasks, but never nore slowly. All materials but one demonstratedthis
sequence.
to
B. The patient's performatrceoften broke down upon a changefront simultaneous
delayedmatching,in identity as well as nonidentity tasks'
b. Oelayed-matching tasks did not always improve in the sarne temporal sequenc
as the correspondingsimultaneousidentity-matchingtasks'
In Fig. 3, identity tasks have larger data points and solid lines. Within each response
category, identity performances inrproved n-rostrapidly, although all single-letterwriting
taski *Lre approximately the same when first tested. In simultaneousmatching, the trends
third,
of improvement were: first, visual-visualidentity; second,tactile-visualidentity;
naming (repeating) came. first'
auditory-visualnonidentity. In naming, auditory identity
then tactile and visual nonidentity. Differentialwriting trends appeared only in the trigram
data; the order was like simultaneousmatching.
Although the patient scored 75 per cent or better on simultaneousmatching, delays
single
causedall his good performances to break down, exceptauditory-visual matching of
matching was the reverse of
letters. The order of improvenrentin delayed single-letter
also lagged behind delayed
simultaneousmatching. Delayedvisual-visualtrigram matching
tactile-visualmatching; delayedauditory-visualmatchingwas not tested,sincesimultaneous
rnatchingwas nevergood.
The left side of Fig. 4 shows the trends when the patient matched, named, or wrote
and
3-letter words. There ivere two types of visual samples,3-letter words and pictures,
patient (aud. sp.), or pronounced
two types of auclitory samples,3Jetter words spelledto the
(' a u d .p r . ) .
Alain, identity tasks improved first. In matching and writing, the patient improved
rnostrapidly in responseto visual and tactileword samples;next, to pronouncedor spelled
was
samples;and last, to pictures. The identity naming task, repeatingpronouncedwords,
(testedrelatively late)'
.head of all nonidentity naming exceptpronouncing spelledwords
All rnatchingbroke clown during the early delay tests' Delayed matching did not clearly
prescrvethe identityon-nidentityrecoverysequence.
t26 M. SrnveN,L. T Stooo,rno J. P. Mosn and J. Lncrsrrn
WoRDs
3-[ErlER cotol NAMES
tr'
fl
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Ylr , / \
t l / ) ''\oud(pr.)
1--.-,i-\-J.
o DEI-M
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W RI I I N G
.-. -:_._.
(, WRIIING
z
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1,1i'{ / - .
E
B Prct. a r I
a
B /-6 \ -rY', r"
o
,ilt ; ;u's.l
r 3 5 7 e 1 1B J i r r * f 2 1 2 3 2 5 2 7 2 e 3 111 3
3 5
5 7 9 t1 l1 1
7 e 13t5
5 11 771s9129122 1t 22 5t 2 5
7 22 97t21 e t 1
WEEKS
Ftc. 4. Testscores
asa functionof time;responses
involving3-letterwordsandcolornames.
Performancesin the right side of Fig. 4 involved color names in the responses. Colors
or color names provided the input. The only identity tasks administered,auditory-naming
and visual-writing of color-name samples,improved earlier than or along with nonidentity
naming and writing. The matching tasks,both nonidentity, broke down when delay was
introduced.
'On
the left side of Fig. 5 are trends for word-pictureand picture-picturematching.
Sampleswere the samepicturesand visual,tactile,spelled,or pronounced3letter words as
in Fig. 4. The only identity task, simultaneouspicture-picturematching,was ahead of trll
the others,but did not break down in delayedmatching.
Colors were choicesin the matohingtasks on the right side of Fig. 5. Sampleswere
colors and visual or auditory color names. Simultaneouscolor-color identity matching,
perfect in the first test, broke down when delay was introduced. Ratesof improvementin
delayedand simultaneousmatchingfollowed a similar sequence.
The patient'sscoreson sayingand writing the namesof picturesand colors, not sho\4'r1
in Fig. 5, were included in Fig. 4.
Figure 6 summarizestests in which sampleswere visual or tactile digits, visual or
auditory digit names,and visual or tactile dots. The dots varied in pattern but corresponded
tsEHAVIORAL STUDIES()F' APHASIA: MF,THODSOF INVES'I'IGAI'ION ANI) ANAI,YSIS t27
,:
L'
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oud
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d._ col. no.
5IM. MATCHING
6 v
e
.t 3 5 7 9 11 13151719212325272931 1 3 5 7 9 1r 13151719212t25272931
WEEKS WEEKS
Frc. 5. Test scores as a function of time; matching-to-sample with pictttres and color choices.
DOTS
DIGII NAMTS
o"d
" "
d '
---.:.,' dis :
f:
i=-::*_------_-_ -. :-;i-;:t't- aig;-]ti'
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roc.di9.- j
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ais
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Dt. MATcHTNG
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| 3 5 ? 9 1 11 3 1 5 1 7 1 9 2 1 2 3 2 5 7 7 2 9 3 11 3 5 7 9 Itt3't517 t9 1 3 5 t 9 fi 't3151719
WTIKS WEEXS WEE(S
Frc. (r. Test scores as a fLtnction of time; responses involving digit names, digits, and dots
l2tt M . S t t > u r w , L . T . S r o l r t > a n t r ,J . l ' . M o H t l a n d J . L E l c F . s l T R
i n q u a n t i t y t o t h c a l t p r o p r i a t cd i g i t . l n t c s t si n v o l v i l t gd i g i t t t a n r c si t s r c s p ( ) l l s c(sl e l i s i t l c
o f F i g . 6 ) , t h c o n l y i d e n t i t y t a s k g i v c n w a s a u d i t o l y - n a n r i n g( r e p c t i l i o no l ' c l i c l a t c dd i g i t
n a m e s ) .W l r e nt e s t e d t, h i s w a sa b o v eo r e q u a lt o n o n i d e n t i t yn a n i n g . S i m u l l a n e o um s atch-
ing tasks,all nonidentity, were perfornled well in their first tests and all broke down when
delay was introduced.
In the center column, responsesinvolved digits rather than digit natlles. All writing
was performedwell when first tested. Identity matching of visual digits, perfectin the first
week,broke down in delay. Tactile-visualmatchingwas considerablyweakerthan auditory-
visual in the secondweek, the only instancein which an identity task fell behind a non-
identity task involving the samechoicestimuli.
The third column shows trends for nonidentity rnatchingof digit samplesto the ap-
propriate numbersof visual dots.
Samplesin Figs.7 and 8 werecomnlon objects,seenor palpated,or their spokennalnes.
The only identity task in Fig. 7, auditory-naming(repeating),ranked ahead of nonidentity
namins.
O B J E C IN A M E S
z
U
E
u
e
t
o
U
| 3 5 7 9 1113151719212321272931
WEKS
involvingobjectnames'
Frr;.7. Testscoresasa functionof time; responses
OBJECIS
,:
U
o
D E L .M A I C H I N G
o l
z =
o U
B <
c i
F ( ,
r r E MAICHING
c 3
E
? 9 1 1 1 3 1 5 1 7 1 9
WEEKS
Frc.8. Testscoresasafunctionoftime;matching-to-samplewithobjects(pictures)aschoices.
(errors per opportunity) was 40 per cent, compared with 2l per cent when upper-case
samples-wermembers of similar pairs. Error rates showed no such differencebetweenthe
two sets of letters when samplesand choices both were lower case. Hence, within tactile-
visual matching of single letters, identity tasks were performed more accuratelythan non-
identity.
Table 1. Error ratesin matchingUpper-case
and Lower-casesampleletters with Lower-casechoices
Samples
Upper-case (%) Lower-case ('/')
Dissimilarpairs 40 27
1l
Similarpairs 2l
Samplelettersfor writing were lower case,but the patient was reinforced lbr correct
writing or printing in either rlpper-or lower-casestyles. Lower-caseprinting predominated
in his iesponsesto visual or tactile 3-letterwords. He preferred to print upper-caseletters,
however, when sampleswere auditory and their form unspecified. The difference supports
the view that this patient'sletter-writing fron visual or tactile sampleswas an identity, or
copying, task. writing trigrams,color names,and digit nameswere similarlyconsistent'
posNnRand Mrrcspr-l [8], using upper- and lower-caselettersas well as other stimuli.
found that normal adr.rltsmatched physically identical stimuli more rapidly than physically
different stimuli which had the same class names. Their analysis suggestedstrongly that
different levels of stimulus processingwere involved in the identity and nonidentity tasks.
Defcits classified ss input, output, or relationql
One can rule out input deficit as an explanation for a subnormal performance by show-
ing that the patient can, under some circumstance,respond normally to the same stimuli.
For example, even while our patient had trouble naming visual letters, he wrote and
matched those same letters (Fig. 3). Therefore, his problems with visual letters could not
be classifiedas input deficits. [n the early rveeks,however,no test with tactileletter samples
130 M . S r o p r r N , L . T . S r o l ) D A R n ,J . P . M o H n a n d J . L a t c r s r r , r r
\ v a sn o n r l a l ; l a c t i l c i n p u t d e f i c i tf o r s i n g l el e t t e r sc o u l d n o t b e r u l e d o u t u n t i l l a t c r .
To exclude output deficit, otle must show that thc patient can exccutethe responsc
s a t i s f a c t o r i l tyt n c l e rs o m ec i r c u m s t a n c eF. o r e x a n r p l c c, v e n w h i l e o u r p a t i e n t h a d t r o u b l c
n a n r i r r gv i s u a la n d t a c t i l el e t t e r s( w e c k6 a n d l a t e r ' I)r cw a s a b l c t o n a n t ea u d i t o r yl c t t e r s :h i s
s u b n o r t n a l e t t e r - n a n r i nw g i r sn o t a n o u t p u t d e l i c i t . O u t p u t d e f i c i tc o u l d n o t b e r u l c d o u t ,
however,bel'oreintact rcpetition had beendemonstrated.
If input and output are intact, a subnornralpcrforrnancethat involvesthe intact ele-
ttlentsmust, by exclusion,fall into the relationalcategory. It indicatesa deficient stinrulus-
r c s p o n s er e l a t i o n .
This patient's early deficits werc difficult to classify becausehe ctid not havc all the
t l e c e s s a rtye s t s ,b u t s t a r t i n gw i t h w c e k s( r - 7 ,a c o m p l e t ea n a l y s i sw a s p o s s i b l e .[ . i k c s i r r g l e
l et t c r s ,v i s u a lt r i g r a ms a m p l c s( F i g . 3 , w c e k s6 a n d 7 ) l e d t o s a t i s f a c t o r sy i n r u l t a r r e o unsr a t c h -
i n g a n d w r i t i n g ; a u d i t o r y s a n r p l c sw e r c n a n c d a d e q u a t e l yt;a c t i l es a t n p l e sp r o d u c e csl a l i s -
factory sitnultaneousmatching. Each modality was involved in at least one satisfactory
performance,demonstratingthat each trigram input was intact.
On the output side,identity matching, naming, and writing were satisfactoryin weeks
6-7, demonstratingthat cach output was intact. Subnormal performanceswith trigrams
were neither input nor output deficits.
Similar analysisof Figs. 4-8 revealsat least one satisfactoryperfbrmancewith each
input, and at leastone instancein which eachfornl of responsewas good. With input and
output deficitsruled out, all dcficitsafter rveek5 nrust be classifiedas relational.
An examination that fails to combine each output with each input may lead to mis-
taken identificationof the cleficit; in weeks l-5, before identity narning had been tested,
one might have concludedthat the patient suffereda narning ontput deficit. Also, if the
patient is testedearly, before various input-output combinationshave revealeddifferent
recoverycourses,one may fail to observeinput or output deficitsresolvinginto relational
deficits.
A U D I I O R YS A M P L E S
VI SUAI' SAMPI.ES nodrn9
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IACIILESAMPTES
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1 3 5 7 9 1 1 1 3 1 5 1 7 1 9 2 1 2 3 22 57 2 9 J 1 I 3 5 7 911 13151?1921232527
WEEKS
naming
Frc.9. Nonidentity andwritingin response to thesamesamples. Visualsamplesleft
column;auditorysamples,upperright; tactilesan'rples, (pic-
lowerright. Samplematerials
tures,colors,etc.)areidentifiedon eachframe.
responses are conparable only when the input remainsconstant. A consequence of failure
to observethis restrictionis illustratedby Fig. 10, in which a comparisonof our patient's
auditory-writing with visual-namingfails to reveal the differencebetween naming and
writing.
A secondfeature is our avoidanceof the term "reading" as a responseclassification.
Readingis a term appropriate both to sayingand writing the namesof visual (or tactile)
stimuli, but not auditory stimuli. The operationalresponseclassifications,(oral) naming
and writing, encompassreading as expressedin speechand writing, yet pernit separate
examinationof both responsesto visual and auditory stimuli, whether or not the perfor-
mancecan be labelled"reading".
Combinedmodality-materialspecificityand naming vs.writing. The role of visual words
in this patient'sdeficitshelpsexplain the unusualsuperiorityof naming over writing (Fig. 9).
Naming and writing werecomparedonly as responses to the sanresamples,and visual word
sampleswere eliminatedbecausethey permitted identity writing, or copying. Becauseof
theseconstraintsvisual words were never inputs in naming tasks that could legitimatelybe
comparedwith writing. All writing, however, had visual words as response-producedinput
from the writing itself (Fig. 2).
Bt ilAVl()RAl.Sl(Jt)lls ()l At'll,'\slA: Ml;lll()t)s ()l: tNVtsll(ilAll{)N ANI) AI NAYSS I .1.1
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to auditorysamples,
Frc. 10. Nonidentitywriting responses to visual
and namingresponscs
samDles.
As noted before,visual color namesdid not produce the same unique relational deficit
as visual picture or digit llames. Consistentwith this, rvriting color names was the sole
exceptionto the rule that writing was inferior to oral narning (Fig. 9).
This patient'srelationalwriting deficitwas at leastin part secondaryto the more general
visual-wordrelationaldeficit.
Matching vs. naning and y,riting. Nonidentity matching of names to various input
stimuli usually improved rnore rapidly than or along with saying or writing the names.
However,this generalizationwas weakenedby certainexceptionswhich reflectedthe visual-
word relationaldeficitsdescribedabove; the patient'sdata are not conclusiveon this point.
Delayed matching-to-sample.Did the delayed-matchingdeficits fall into the same cate-
gory as other relationaldeficits,or is a memory categoryrequired? Someevidencesuggests
that the delaydeficitswerea secondaryconsequence of relational deficitsother than memory
The change from simultaneousto delayed matching introduced two new factors
First, the sample was no longer available when the patient made his choice. If sample
disappearancecausedthe clelayed-matchingdeficit, length of the delay would be immaterial.
Delay clurationwas the secondfactor. If the time interval werecritical, mere disappear-
anceof the satnplewould causethe patient little difficulty,but longer delayswould produce
more errors.
The adjusting-clelay proceduredoesnot easilylend itself to the differentiationof sample
disappearance and delay duration. The longestdelay the patient can attain in 20 trials may
be influencedby the extent to which absenceof the sample,by itself, causeserrors. The fol-
lowing considerationssuggestthat this patient'sdelayed-matchingdeficitswere a function
of sampledisappearance per se.
First, even in the early weeks the patient did not show clinical signs of the global
amnesiathat would be expectedif his severedelayed-matchingdeficits reflected a memory
loss.
134 M. StoulN,[-. T. Srouorno,J. P. MonnandJ. Lntcpsrsn
w h i c h o u r m c t h o d s a r e a p p l i o a b l e .A t t h e o t h c r c x t r e n r e p , a t i c n t sw i t h s r - r b t l car p h a s i c
disorderswill do all our tests pcrfcctly. Theref'ore,tlrc rrrcthodswc havc prcscntedafc
a p p l i c a b l et o p a t i e n t sw h o s ec l e f i c i t ls- a l li n t o a n r i c k l l cr a n g eo f s c v c r i t y . W i t l r i n t h i s r a n g e
s o m e p a t l e n t sm a y s h o w o n l y a f c w d e l j c i t so r e v c no n l y o n e , r e s t r i c t c dp c r h a p s1 o a s i n g l e
stimulus-response relation, while othcrs nray show widcsprcadproblcnts of sevelaltypes.
The presentpatient fits into the latter category. I'lis paltcrn of dcficiencyand nornral pcr-
formance provides a basis for comparison with other classificationsystclljsand patients.
and for testingcertain theoriesof higher nervousfunction.
DeJicient nonidentity and intact identity perJbrinances. Consistently intact identity
performancesautomatically rule out input ancl output clcficits. HEln [10] has also noted
the importanceof intact identity perfornranceas a control for the patient's understanding
of the task. In our patient, the identity-nonidentity distinction took precedenceover sti-
mulus modalities,materials,and responses;onlv after classifyingthe identity tasks sepa-
rately was it possibleto analyzethe relational deficits into specificmoclalities,materials,
and responses.
The identity classificationrecognizesthat patients may do some rratching, naming,
and writing tasks as identities,but normal adr.rltsubjectsare likely to do them as non-
identity languagetasks,via naming. It is of interestto note the finding of Brncs and IJonr-
Nrn [1] that first-gradeand older children are lnore likely to rnatch objectson the basis
ofclass or functional attributes(nonidentity) than contnronstinrulusproperties(i<tentity),
while youngerchildrendo the opposite. A pal.ient'streatnent of letteisor rvordsas identities
s u g g e s t tsh a t t h e c o n t r o l l i n g s i i n i u l i a r c l c t t c r sa s s h a p c s ,n o t l e t t e r sa s l a n g u a g e ;l n e r e l ) '
sounds,not soundsof a word. Becausehe cannot processlettersand rvordsinto language.
he learns to attend to asp;cts of those stimuli rvhich would not normally exert exclusive
control over his responses.Our paticnt's early iniproverncntsin idcntity tasks probably
reflect his learning substitute behavior rather than his recovery frorn cleficit. Since the
stimulus aspectsto which the patient reactsmay clifferfrom those the examiner specifies,
comparisonsof identity lvith nonidentity tasks in tests of language,of specificagnosias,
or of inter- vs. intra-modalityintegration,are likcly to be invalid. TruaER| 2] has provided
an excellentdiscussionof this and relatednratters.
Failure to attend to stimuli as languagemay seernan input deficit. I-anguage,however,
unlike shapeor color, is not a physicalstimulusproperty, nor is it speechor any other single
output. Languageis a relational processthat includesinput and output. A general dc-
ficiency in this relation will, if a patient can discrin-rinate physical stimulus diinensions,
cause an attentional shift, reflectedin good identity and concurrently poor nonidentity
performances.Thus, the faster improvementsin identity than nonidentity tasks were pro-
bably secondaryto, and actually dernonstrativeof, continr-ring relationaldcficits.
The identity-nonidentitydistinction assumesadditional inrportancewhen one recog-
nizesthat not all patientsshow the same patterrr. Patientsrvith morc rcstrictecllanguage
deficienciesmay show impairment prcdonrinantlyf<lr 1;alticularstiliuli and responsesin
nonidentity-tasks,for examplecolor naming ! 3], matohingspoken lcttcr natnesto printect
l e t t e r s[ 9 ] , o r n o n r e p c t i t i v eo r a l n a l r i n g f l 4 ] . P a t i e n t sw i t h r i g h t - h c m i s p h c rlce s i o n sm a y
even be rnore delicicnt in certain iclcntity thun norridentity tasks, fbr er.amplein tactile-
visual vs. auclitory-visualmatching of letters! 51.
Relatbnal noming deficits. Our patient was able to repeat words when he could not
say them in responseto appropriatc visual and tactile stimuli. He was able to match and
write visualand tactileword samplesthat he could not name. His namingdeficits,therefore,
BEHAVIORAL STUDII]S OTI APIIASIA: METHODS oT INVF]STIGATIONAND ANALYSIS '3'7
REF'ERENCES
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Reprintcd in J. Trvt-on (Ecl.), Selat'tul Writirrgs oJ'John Hughlitrg,rJrtckson. Vol. 2, pp. t-55-170. Basic
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deficits in a dysphasic yotrth. Arths. Neurol. 18, 549-562, I 968.
I0. Hnao, H. Aphasia and Kindred Disonl<'rs oJ Spaech. Cambridgc Univ., l.ondon, 1926.
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Genct, Psychol. 109, 195-104, 1966.
12. Trulr.n, l"l-L. Perception. ln Mtr-xt,t, B. and l'r-r-rnr,R H,. - L . A l t c r - a t i o n o f p e r c e p t i o n a n d n t e m o r y i n
m a n : r c l ' l c c t i o n so n m e t h o d s . h ' r A t n l y s i s o J B e h a v i o r u l C h a n g c , L . W r r s r u n r z , (Editor),pp. 268-
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of the dellcit in total aplrasia. ln prcparation.
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, . , S t o u u n n u , I - . T . a n d M o r r n , J . P . S o m e d e t e r r n i n a n t so f v i s u a l n e g l c c l .
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I t j . G r s c r t w t N u , N . l ) i s c o n n e x i o n s y n d r o r n c si n a n i n r a l s a n d n r a n : l > ' a r tl l . B r u i n 8 8 . - 5 8 5 - 6 4 4 ,1 9 6 5 .
. 1 9 . C a z z r n l c ; , r , M . S . , B o c ; l r r , - 1 .[ : . a n d S p r r n n v ,I { . W . S o m e f u n c t i o n a l c l l e c t s o f s e c t i o n i n gt h e c e r e b r a l
c o m m i s s t r r e si n n a n . P r o c . N a t . , 4 c a d . S r i . 4 8 , 1 7 6 5 - 1 7 6 9 ,1 9 6 2 .
2 0 . G n z z r N t c . , r , M . S . , B o c l N , J . I l . a n d S p l , n n v , R . W . O b s e r v a t i o n so n v i s u a l p e r c e p t i o l l a f t e r d i s c o n -
nexion of the cerebral hemispheres in man. Brain 88, (pt 2),221-236, 1965.
21. (irrzznNrcA, M. S. and Slrnnv, R. W. Language aftcr section of the celebral comnrissures. Brarir
9 0 , ( P t r ) , 1 3 1 - 1 4 8 ,t 9 6 7 .
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v l m , j t q , w s x , l . r v p ,x b f , d k b , w p j , b f . i . c t d ,
ckl, nqs
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B i n e t , a n d t h c p o l y l i n g u a l m a g a z i t . r cQ u i n t o L i n g o . A l l t l - r e s et c x t s w e r e r e a d a l o u d a s n e o l o g i s m s
or with
s u b s t i t t l t e d s h o r t w o r d s . I n t h c S t a n f o r d - B i n c t s u b t e s t , h e a c c e p t c d a s c o r r e c t s e n t e n c e sw i t h
scrambled
w o r d o r d c r . A l t h o u g h h e r c f t r s c dt o a t t e n r p t t o r c a d a l o u d f r o m s i m u l t a n e o u s l y - t r a n s l a t e dt e x t f r o m
erinlr;
L i n g o , h e s c p a r a t e dt h e L n g l i s h t c x t f r o n l t h a t o f o t h e r l a n g u a g c s ,a n d i l e n i c d e v e r h a v i n g
seen bel'oie the
c h a r a c t c r si r l t h c R t t s s i a nt e x t . A l t h o r " r g hl r c r n i s r r a r n c r*l i r h n c o l o g i s r n s ,l r c c o r r e r : t l yp o i n G < i t h c m i s s i n g
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J / J c o n l n l o n s o u n c l sl t c l a i l e d t o n t r n c . l l c t l c l i r r c r l- 5 / 5d i c t a l c d w o r r l s f r o r n t h c w c x l c r v o c a b u l a r y
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R 6 s u m e - A p a r t i r d ' t r n e a n a l y s e f o n c t i o n n e l l e d e s r c l a t i o n s s t i m u l u s - r 6 p o n s e( l e c o n t r d l e d L l
c o m p o r t c l l l c n t p u r l c s t i r n u l L t s )o, n a t l e r i v 6 d c s m i ' t h o d e s d ' e x r m e n c t d ' e n r l y s e d c s d 6 f i c i t ,
c o m p o r t e n l e n t a u x d a n s I ' a p h a s i e . L e s d i f i c i t s e t a i e n t c l a s s 6 sc o m m e d e s e f f o n d r e m e n t s d e s
t ' c l a t i o n sd t r c o n t r 6 l c s t i r r u l u s - r c p o n s c ;d e s p r o f i l s d e p c r f o r m a n c e s ,d i f i c i t a i r e s e t i n t a c t e s ,c h e z
t t n s u j e t a t t e i n t d ' a p h a s i es t v i r e i l l u s t r c n t I ' i n t a r e t d e l a m 6 t h o d e . L a d i s t i n c t i o n e n t r e p r e u v e s
d ' i d e n t i t i e t d p r e u v e sd e n o n - i d e n t i 1 6r e s s o r tc l a i r e m c n i c l e sd o n n d e sr e c e u i l l i e s .C e t t e d i s i i n c t i o n
p a s s e a t r a v e r s l e s d i l l 0 r e n t e s r e p o r r s e s ,l e s m o d a l i t 6 s e t l e s m a t 6 r i e l s d e s t i m u l u s .
En
examinant scparement ces deux types d'6preuve, on obtient une classifcatigrr plus precise des
dcficritsdu rraladc selon lcs catdgorics d'cntree, de sortie ou de relation, chacune de celle-ci i
son tour pouvant 0tre classce selon un type specifique. Les donnes recueillies demontrent
que des examens r6pftcs sur une pdriode prolongde dc temps peuvent r-ep3rerdes changements
d e c l a s s i f i c a t i o nd u d , : f i c i t , r ' t - t o t l i f i c a t i o nqsu i n ' a u r a i e n t p a s 6 t 6 n o t 6 e si n u t i l i s a n t s e u l e m e n t
l c s t c s t sh a b i t u c l s .
Z u s a t n m c n f i t s s u n g - T c s t n r e t h o t l c nu n t l V c r l r a l t c n s a r . r a l y s cbnc i A p f u a s i k c r nw u r d e l a u s e i n e r
f u n k t i o n a l c n l ) r i . i f u n gt l c l l { c i z r c a k t i o n s b c z i c h u n g c rar b g c l e i t c t . t j i c M e n g c l r v u r c l e na l s K o n -
t r o l l v c r s a g e n d i c s e r B o z i e h u n g c nk l a s s i f i z i e r t . A n . r B e i s p i e tc i n e s s c l r w e r a p h a s i s c h g c s t i i r t e n
K r a n k c n m i t c i n c m M a n g e l p r o f i l u n d t e i l w e i s ei n t a k t e ; L e i s t u n g c n w u r . d e d i e F r u c h t b a r k e i t
d i e s e rU n t c r s t t c h u n g s m c t h o t l c nd c r l o n s t r i c r t . A u s d e n l ) a t e n k o n n t e i - n a ne i n e U n t e r s c h e i d u n g
zwischcn identisclren und nicht identischen Aulgabcn trelTen und so einen kiirzeren Weg bei dei
C)rdnung verschiedener Reaktionen, Reizmodalitiiten und dem Priifungsmaterial cinsChlagen.
Die getrenn te Priifun g dcr genanntcn beiden A ufgabentypen erlaubte eini feinere Klassitjkation
d e r M i i n g e l n a c h I n p u t , C ) u t p u t o d e r n a c h R e l a t i o n s k a t e g o r i eu n d s p e z i f i s c h e nU n t e r t y p e n .
Die Ergebnisselicllen dariib.e'rltinaus erkenncn, dat! die Wiedcrholungvon Testuntersuchungen
t-iber lzingere Zeit zv einer Anderung der Stdrungseinteilung fiihren kann, was auf der Bisis
fr0herer Testpriifungen rricht moglich war.