Training the short- and long-term verbal recall of a postencephalitic amnesic

Self-Instruction in the Training of Functional Skills: A Single Case Study

This article presents a treatment programme for the development of personal hygiene behaviour in a patient who had herpes simplex encephalitis 5 years earlier. The patient has severe memory and organisational problems, but is of average overall intelligence. The programme consists, in part, of chaining a series of nine discrete activities by using linking phrases. The programme allowed the patient to structure his behaviour and wash in a well organised non-repetitive way. The results are discussed in the light of previous failures to affect behaviour using apparently similar methods.

Computer-aided cognitive rehabilitation: possible application to the attentional deficit of schizophrenia, a report of negative results

The cognitive deficits associated with schizophrenia commonly include impairment in attention, which may contribute to difficulties with learning, memory, and executive function. This study evaluated the effectiveness of computer-aided training of attentional skills in schizophrenia. Two groups of schizophrenic subjects (9 men and 1 woman) were matched for age, estimated premorbid IQ, and positive and negative symptom scores. Both groups were assessed using a battery of attentional tests. Subjects then received either six 1-hr. computer-aided cognitive rehabilitation sessions (experimental condition) or six sessions of graphics-based computer games (control condition). Both groups were reassessed with attentional measures. There was significant improvement on only one test, a letter-cancellation task. This improvement was evident in both groups suggesting that this was a practise effect. Apart from the letter-cancellation test, subjects undertaking the computer-aided rehabilitation treatment did not show significant improvement on any attentional tasks.

Cognitive rehabilitation: a neuropsychological speciality comes of age

In its first decade cognitive rehabilitation has emerged from infancy with the energy and much of the turmoil of youth. It has become an established speciality in brain-injury rehabilitation and has inspired many neuropsychologists to broaden their expertise beyond diagnosis and address their efforts to intervention. Restoration, although controversial, is an important and valid goal at the outset of cognitive rehabilitation, whereas the substitution of other means of goal achievement and environmental redesign are significant components of a comprehensive neuro-rehabilitative treatment programme. Efficacy is being demonstrated in many ways, ranging from increased patterns of use to controlled empirical studies. Few continue to raise the naive issue of whether there is any scientific basis for this neuropsychological speciality; instead, questions have become more focused on understanding the process of change to best serve human needs. In the next decade the refinement of current approaches can be anticipated, as well as the breaking of new ground. Neuropsychologists specializing in cognitive rehabilitation are likely to be turning their attention to underserved populations, such as those emerging from protracted coma, individuals suffering from 'progressive' neurological conditions, and persons whose brains were injured early in development. Scientific (theoretical, methodological and empirical) developments in cognitive psychology will help to delve more precisely into the underlying basic processes, including the sensory substrate. We will be challenged to address specific applications, such as advising people with known or suspected cognitive deficits who wish to drive.

The psychological treatment of memory impairment: a review of empirical studies

Memory impairment is a frequent effect of many different forms of brain dysfunction. Memory impairment is also a frequent focus of treatment interventions, and there have been many different treatment methods suggested. The suggested methods include direct retraining, the use of spared skills in compensating for the impairment (alternate functional systems), and the use of behavioral strategies to circumvent the manifest memory dysfunction (behavioral prosthetics). Unfortunately, there are very few studies comparing the various suggested treatment methods. The present paper evaluates the empirical evidence related to the treatment of memory dysfunction and suggests directions for future investigations. Although the evidence is not conclusive, it appears that some forms of treatment may be helpful in remediating certain types of memory impairment. An approach likely to be productive would include some consideration of the impaired neurological and psychological mechanisms responsible for the manifest memory deficit as well as a consideration of the etiology of the injury thought to be causally related to the memory deficit. As yet, there have been no rigorous empirical evaluations of these considerations.

Effects of training in use of executive strategies on a verbal memory problem resulting from closed head injury

This case study reports attempts to improve the recall performance of an adolescent (GC) who had suffered a closed-head injury. GC had a very limited range of ways of processing both spoken and written information and showed significant recall problems. Initial training in the use of strategies for list learning resulted in improvement in paired-associate recall but showed that initiation and use of the newly learned strategies would not occur without prompting. Executive strategy training was provided to improve GC's ability to identify a memory problem and to initiate a general plan for dealing with that problem. This training involved consideration of task analysis, strategy selection and initiation, and monitoring of strategy use. Evidence of long-term maintenance of improvement in level of recall on both paired-associate and free recall tests was noted following the executive strategy training.

Training functional skills following herpes simplex encephalitis: a single case study

This paper presents a treatment program for the development of personal hygiene behavior in a patient who was 5 years post herpes simplex encephalitis. The patient has severe memory and organizational problems, but is of average overall intelligence. The program consists in part of chaining a series of nine discrete activities by using linking phrases. The program allowed the patient to structure his behavior and wash in a well-organized nonrepetitive way. Results are discussed in the light of previous failures to affect behavior using apparently similar methods.

Attempted clinical application of a technique for promoting robust free recall to a case of alcoholic Korsakoff's syndrome

A case study is reported which attempted to teach personal orienting information (i.e., recent history) to an amnesic male patient. The structured cuing methods reported by Kovner, Mattis, and Pass (1985, Journal of Clinical and Experimental Neuropsychology, 7, 395-411) were adopted. This involves structured presentation and cuing of target words embedded in a narrative. Some patients eventually are able to freely recall large amounts of material presented in this way. In the present case, the patient received 30 training sessions over 8 weeks. The material to be remembered was 10 target words pertaining to recent personal history. These words were embedded in accompanying storyline. The patient's immediate recall at the end of each session improved to some extent over the training period. However, delayed recall for the material remained nil throughout. Twelve months after the last training session the patient showed some "implicit" retention of the material. The findings are contrasted with Kovner et al.'s dramatic results and discussed.

Assessment and treatment of cognitive deficits in brain-damaged individuals

Rehabilitation professionals are recognizing the need for greater emphasis on treating cognitive as well as physical deficits in brain-damaged individuals. This review discusses recent advances in the development of treatments for patients with cognitive deficits secondary to brain damage. The review will focus upon treatments developed for problems with attention and vigilance, memory, language and reading abilities, visuoperceptual functioning, and driving skills. An overview of the treatment process presents the role of assessment and case conceptualization, patient and family education, application of rehabilitation interventions, and approaches to promoting recovery generalization and maintenance of relearned abilities.

Effectiveness of an attention-training program

Attention Process Training (APT), a hierarchical, multilevel treatment program, was designed to remediate attention deficits in brain-injured persons. The program incorporates current theories in the experimental attention literature. Four brain-injured subjects, varying widely in both etiology of injury and time post onset, underwent intensive cognitive remediation including 5 to 10 weeks of specific attention training. Results are displayed using a single subject multiple baseline across behaviors design. All four subjects demonstrated significant gains in attention following the initiation of attention training. Remediation of another cognitive function (visual processing) was not associated with alterations in attention behavior. The merits of a process-specific approach to cognitive rehabilitation are discussed.

Enduring psychiatric and neuropsychologic sequelae in the post-encephalitis patient

Initial presentations of encephalitis are sometimes misdiagnosed as psychoses due to the predominance of psychiatric symptoms and frequently negative neurological work-ups. It is likely that many of these errors are never discovered. The patient described herein is an exception. Her symptoms, diagnosis, and treatment have now been followed for nearly two years and suggest not only that the initial diagnosis was in error but also that both psychiatric and organic symptoms can endure as sequelae of encephalitis. Questions regarding optimal treatment and reasons for clinical improvement are addressed.

Hypotheses on mnemonic information processing by the brain

From a neuropsychological point of view, hypotheses are offered on the possible action of the brain in the processing of mnemonic information for long-term storage (or for retrieval of long-term stored information). It is argued that strict relations between damage of circumscribed brain structures and amnesia, as they have been suggested in recent case reports, are questionable for several reasons: Firstly, the involved regions differ between cases; secondly, there is some counter-evidence from other cases in which similar neuronal damage failed to result in lasting amnesic disturbances; thirdly, it is hypothesized that even from circumscribed brain damage it is not justifiable to conclude that the lesioned structure is solely or principally responsible for the observed mnemonic changes, as the brain acts in an integrative way, that is, on the basis of a wide-spread network of neuronal information processing. On the basis of these and related arguments, hypotheses and models on mnemonic information processing in the intact and in the damaged brain are derived. With these hypotheses even the frequent observation of interindividual differences in mnemonic information processing finds a possible explanation which is in conformity to known anatomical circuits and connections and to principles of neuronal coding.

The neuropathology of amnesia

Relations between brain damage and memory disturbance are outlined with emphasis on the so-called amnesic syndrome. Following a brief introduction into forms of memory and memory failures, the basic causes of brain damaage (with relevance to amnestic failures) are described. Thereafter, the two best-known forms of brain damage-amnesia relations are reviewed: the consequences of damage to medial temporal lobe structures and to diencephalic regions. For the cases with medial temporal lobe damage, evidence is reported in greater detail for H.M., who has been examined more than any other amnesic patient for more than 30 years now, as a considerable amount of literature has accumulated on his behavior in diverse situations. Other cases with more or less circumscribed damage to medial temporal lobe structures are reviewed so as to outline criteria for or against the hypothesis that there are regions within the medial temporal lobe whose damage might be critical for the amnesic syndrome. Two cases of diencephalic amnesia are summarized in particular (cases of Mair et al., 1979) as they have received extensive neuropsychological and neuropathological investigation. Other cases with, for example, Korsakoff's disease are reviewed, as well as cases with diencephalic, or combined mesencephalic-diencephalic damage without nutritional causes. A third group of patients with massive, but still selective amnesic disturbances are then described: cases of basal forebrain damage, followed by descriptions of Alzheimer's disease which has similarities in the underlying neuropathology. This leads over to cases with more generalized intellectual deteriorations (dementia), which may have developed on the basis of primarily cortical damage or damage principally to basal ganglia structures. After reviewing cases with mainly material-specific memory failures--usually as a consequence of restricted neocortical damage--a separate section follows on patients in whom retrograde amnesia is the prominent symptom. The contribution of animal models of human amnesia is critically reviewed and discrepancies are analyzed between human and animal memory disturbances. This section emphasizes the value of investigating inter-dependencies between brain structures by pointing out that relations between memory disturbances and brain damage may be more complicated than apparent from a simple structure-function assignment. This aspect is further followed up in the conclusions.

Amnesic syndrome: a lesion-specific disorder?

This paper reviews various lines of evidence which suggest that organic amnesia stemming from lesions of the temporal lobe region produce an amnesia that is qualitatively different from that produced by diencephalic lesions. Differences between these two classes of amnesia were found within five dimensions of performance; (a) insight, concern and confabulation, (b) retrograde amnesia, (c) forgetting rate, (d) frontal lobe symptoms, (e) sensitivity to interference in short term memory. The range of differences found suggest that temporal lobe and diencephalic amnesics should not be considered as suffering from the same type of "amnesic syndrome". It is proposed that future experimental work on amnesia should take full account of neuropathological differences between amnesic patients.

An individualized memory retraining program after closed-head injury: a single-case study

A memory-retraining program was designed for a patient approximately 2 1/2 months after he suffered a closed-head injury. Tests showed his memory deficit to be relatively isolated in the verbal sphere. An attempt was made to design a program in which tasks resembled the environmental demands on the patient for retention of verbal material. On a routine basis, the patient was read various paragraphs and was subsequently required to write them from memory. Three different strategies were used in an attempt to improve memory. After 15 days of training, the patient improved from an impaired level of verbal recall to a normal level. Strategies employing (a) visual imagery and other mnemonic devices and (b) questioning during presentation appeared to be most effective in facilitating retention. There was some drop in memory performance at a 9 month follow-up, and the patient was encouraged to resume active use of mnemonic strategies. Implications for further study are discussed.

Problems in measuring cognitive recovery after acute brain injury

The measurement of cognitive recovery after traumatic brain damage raises a number of methodological and practical problems. The precise schedule of testing, the specification of functions to be measured, the separation of practice from recovery, and the specification of appropriate control or comparison groups must all be considered by the researcher. In addition, strenuous efforts must be made to achieve as high a follow-up rate as possible.

Clinical neuropsychology: a discipline in evolution

The future of neuropsychology is considered first in terms of the potential impact of events occurring in clinical medicine, neuroscience research, basic behavioral science and applied psychology, and related disciplines. The focus is then turned inward on clinical neuropsychology itself and a series of suggestions are made concerning how this specialty can evolve to best meet the challenges it will face.

Helping brain-injured people to contend with hidden cognitive deficits

In brain injury, cognitive processes are often impaired. These impairments may be hidden, complicating rehabilitation. We discuss clinical issues in cognitive rehabilitation with particular emphasis on its implications for daily living. For illustration we present two cases of persons with severe, but isolated disorders of memory and visual perception, respectively.