Reabilitação Neurpsicologia

1. Basic Approaches Used in American
and Soviet Clinical Neuropsychology
A. R. LURIA
LAWRENCE V. MAJOVSKI
University of Moscow
Moscow, USSR
National Institutes of Health
Bethesda, Maryland
ABSTRACT: Among that rapidly developing group of
sciences of the nervous system that we now call the
neurosciences, a special place is occupied by neuropsy-
chology. Clinical neuropsychology differs from the
other members of the group of neurological disciplines
in that its concern lies with the role of individual brain
systems in the organization of human psychological ac-
tivity and how these systems are altered upon brain-
behavior disturbance. Two current but differing ap-
proaches, one American and one Soviet, are used in
clinical neuropsychology for assessment of brain-be-
havior disturbance. The Halstead-Reitan Neuropsy-
chological Test Battery, quantitative in approach, is
presented and contrasted with the qualitative syn-
drome-analysis scheme of clinical investigation used by
Soviet neuropsychologists. Both approaches are con-
sidered in terms of their merits, clinical assets and
limitations, influence on generating further scientific
research questions, and contributions to the under-
standing of" the functional organization of brain-be-
havior activity. Fundamental differences in the above
approaches as to principles of work, theoretical dif-
ferences, practical importance for psychology and
medicine, and prospects for clinical neuropsychology's
future are summarized.
Neuropsychology in the United States can be di-
vided into two main subdivisions: clinical and ex-
perimental. These subfields are both concerned
with brain-behavior relationships, but they differ
in their objectives and methods.
American clinical neuropsychology emphasizes
comprehensive approaches to applied problems con-
cerning the psychological effects of brain damage
in humans. It is mainly concerned with quantita-
tive techniques applied to problems of diagnosis,
and there has been no systematic attempt to build
a working theory of the brain's functional orga-
nization in relationship to psychological processes.
Reitan (1966) has described the psychological ef-
fects of brain lesions, using a quantitative test bat-
tery. Clinical neuropsychologists assess intellec-
tual, sensory-motor, and personality deficits, re-
lating these to brain lesions and sometimes to brain
damage in the broader sense, including impaired
physiological function. Clinical neuropsychology,
in the American tradition, has its roots centered
in academic psychology, behavioral science, neurol-
ogy, and especially psychometric measurement.
Neuropsychologists representative of this branch
in the United States include, for example, A. Ben-
ton, N. Butters, M. Lezak, R. Reitan, and A. Smith.
These scientists both conduct research on humans
and perform clinical-diagnostic studies of brain im-
pairment, directly applying knowledge gained (e.g.,
rehabilitation planning). Sometimes their work
even extends to doing therapy with the brain-in-
jured patient.
Experimental neuropsychology's primary objec-
tive is to discover fundamental principles of brain-
behavior relations regardless of their practical ap-
plications. The basic assumption is that carefully
controlled experimental situations will reveal rela-
tionships of greater generality than will direct
study of naturally occurring situations. Most of
the research in this field is performed on animals.
Experimental neuropsychologists, in general, do
not orient their research toward the direct solu-
tion of applied problems. Representative of this
camp are such scientists as K. H. Pribram, R.
Sperry, and D. Bowden.
This article is based on research with the first author at
the Bourdenko Institute of Neurosurgery, Moscow, USSR,
under a grant to the second author from the National In-
stitutes of Health, US/USSR Health Science Exchange
Program, Fogarty International Center, Bethesda, Mary-
land, 1976-1977.
Requests for reprints should be sent to Lawrence V.
Majovski, who is now at the Department of Psychology,
University of California, 405 Hilgard, Los Angeles, Cali-
fornia 90024.
AMERICAN PSYCHOLOGIST • NOVEMBER 1977 • 959

2. Current American Approaches for
Assessing f rain-Behavior Disturbances
Two purposes have guided the development of
neuropsychological test batteries: (a) accuracy in
predicting organic disturbance (Filskov & Gold-
stein, 1974) and (b) understanding of the nature
of organic dysfunctions. Test batteries in the
United States have primarily developed out of the
combined needs of comprehensiveness in standard
data collection. Standardization leads to the use
of an integrated battery of tests administered in
the same carefully systematized fashion to all pa-
tients assessed in order to achieve reliability across
patients.
In American neuropsychology there exist few
formalized batteries for general clinical use, al-
though several have been constructed to meet spe-
cific clinical or research needs: Halstead's (1947)
battery for testing "biological intelligence" in
frontal lobe patients, the Columbia-Greystone bat-
tery for studying the intellectual consequences of
psychosurgery (Landis, 1952), Benton's (1968)
six-test frontal lobe battery, and A. Smith's (1975)
informal battery devised for the psychological as-
sessment of brain disorders, based on a selection of
tests for clinical assessment that can be applied
flexibly, with additions or subtractions to suit the
needs of each patient. Among the formalized bat-
teries for brain damage, one of the most widely
known set of tests in the United States is the
Halstead-Reitan Neuropsychological Test Battery
(Reitan & Davison, 1974).
THE HALSTEAD-REITAN NEUROPSYCHOLOGICAL TEST
BATTERY
The battery of tests Reitan uses was originally de-
veloped from Halstead's attempts to quantify bio-
logical intelligence (Halstead, 1947). The test
battery was developed on the basis of empirical ex-
perience with individual subjects to reflect the fol-
lowing methods of inference: (a) level of per-
formance, (b) specific deficits of pathognomonic
signs, (c) differential scores or patterns of ability,
and (d) comparison of the functional efficiency of
the two sides of the body. It began as a battery
of seven tests selected for their power to dis-
criminate between patients with frontal lobe lesions
and those with other types of lesions or normal
subjects (Halstead, 1947; Reitan & Davison,
1974).
Reitan's "blind assessment" approach—that is,
interpreting results from the Halstead-Reitan bat-
tery administered to a patient without prior knowl-
edge of the patient's presenting complaints, medi-
cal history, or neuroradiological tests—emphasizes
the use of a standard battery of tests. These tests
are designed to reflect, as far as possible, the full
range of psychological deficits associated with
brain lesions, and they attempt to yield accurate
prediction of cerebral dysfunctions in patients.
Reitan (1974) puts it as follows:
The validity of neuropsychological assessment . . . depends
on the validity with which inferences can be made re-
garding the brain. Further, such evidence of validity can-
not be referred to regarding statistical probability levels of
group differences, but must be valid for the individual sub-
ject in question. The best way to accrue evidence that
validity standards of this type can be met is to put neuro-
psychological data to the test of individual prediction in
the form of 'blind' assessments, (p. 201)
The Halstead-Reitan battery consists of the fol-
lowing tests: (a) the Category Test, a test of ab-
stracting ability in which the subject's task is to
figure out the principle relating stimulus subtests
and signal his answer by pressing the appropriate
key on a keyboard; (b) the Tactual Performance
Test, which measures the total time required for
the blindfolded subject to complete a memory task
with the right hand, the left hand, and both hands,
the number of correct figures localized from mem-
ory, and the number of figures recalled; (c) the
Seashore Rhythm Test in which the patient is
asked to discriminate between like and unlike pairs
of musical beats; (d) the Speech-Sounds Percep-
tion Test, which is an auditory test that assesses
the subject's ability to discriminate between simi-
lar-sounding consonants; and (e) the Finger Tap-
ping Test. Added to the above six standardized
tests (but not part of the formal test battery) are
the following: the Trail-Making Test, a visual,
conceptual, and visuomotor tracking test highly
vulnerable to the effects of brain injury; the
Aphasia Screening Test (Halstead & Wepman,
1959); a sensory-perceptual examination that tests
for finger agnosia, skin-writing recognition, and
sensory extinction in the tactile, auditory, and
visual modalities; the Wechsler-Bellevue Intelli-
gence Scale I (or the Wechsler Adult Intelligence
Scale); and the Minnesota Multiphasic Personal-
ity Inventory. Administration time for the com-
plete battery runs from 6 to 8 hours.
A distinctive feature of Reitan's handling of the
examination data of the Halstead-Reitan battery
has been his reliance on test scores for predicting
the nature, site, and presence of the lesion (Wheeler
960 • NOVEMBER 1977 • AMERICAN PSYCHOLOGIST

3. & Reitan, 1963). Reitan uses the Halstead tradi-
tion of utilizing "cutting scores," that is, estab-
lished test-score norms for deciding the level of
severity of the impairment, and the Halstead Im-
pairment Index for making gross diagnostic dis-
criminations. Halstead set the cutting score for
the Impairment Index at a proportion of .50, with
proportions of .40 and lower characterizing the
control subjects. Predictions about the site of the
lesion and its nature (diffuse or focal, static or
changing) are based on statistically identified re-
lationships between test scores. The actuarial ap-
proach has generated development of computerized
interpretations of Halstead-Reitan test protocols
and modified versions of it plus other tests (Rus-
sell, Neuringer, & Goldstein, 1970; Adams, Ren-
nick, & Rosenbaum, Note 1). Efforts to use the
Halstead-Reitan battery for localizing lesions have
had mixed results. This test battery does elicit
differential performance patterns between patients
with left- and right-hemisphere lesions. However,
these right-left hemisphere differences do not oc-
cur with sufficient consistency to warrant basing
clinical decisions on the Halstead-Reitan test scores
alone (Wheeler & Reitan, 1963).
A useful .battery should provide the informa-
tion the examiner wants. If the examiner decides
to rely primarily on one battery of tests for un-
selected clinical patients, then it must be a multi-
purpose battery that will aid in diagnosis, give a
baseline, and supply data for future planning and
treatment of patient needs. There is not, at pres-
ent, any such American test battery that satisfies
all of these criteria. Although standardization pro-
cedures are the heart of reliability assessment at
the present stage of neuropsychological under-
standing, not enough is known to dogmatize any
set of procedures with a full-scale standardization
(Lezak, 1976).
USEFULNESS AND LIMITATIONS OF THE HALSTEAD-
REITAN TEST BATTERY
The Halstead-Reitan Neuropsychological Test Bat-
tery affords one of the more reliable psychological
means of identifying patients with brain-behavior
disturbance, since it has been standardized to give
validity from patient population to patient popula-
tion. In the American tradition of quantitative
psychological measurement, given the validity of
results, one can generalize back to the population
tested for making accurate predictions, in certain
cases, as to the syndrome's nature and site. Predic-
tive efficiency based on validation of results across
brain-behavior disturbances is a powerful tool for
aiding in the diagnosis of brain lesions. Predictive
efficiency is the key in psychometric testing, which
aims to achieve consensual validation of the in-
strument used. The battery's greatest contribu-
tion may lie not in its diagnostic efficiency but
rather in its practicability for assessing brain-be-
havior relationships on a valid basis, making it pos-
sible to test different kinds of behavior when in-
vestigating neuropsychological questions.
The Halstead-Reitan Neuropsychological Test
Battery has limitations at the levels of practical
application and theory in that (a) it takes a long
time to administer (6-8 hours), (b) it has to be
distributed over days, (c) it is unsuitable to ad-
minister, temporarily, if the patient has had a
pneumoencephalogram that is likely to affect the
validity of the test results if examination has be-
gun, and (d) it is not suitable for the thorough
examination of patients with sensory or motor
handicaps or for speech analysis. The most time-
consuming tests are the Category Test and the
Tactual Performance Test (which also are more
highly predictive indicators of brain damage)
which comprise four of the seven tests used in
computing the Impairment Index for brain dam-
age. Reitan prefers reading the test results "blind"
—that is, without prior knowledge of the patient's
history or of any medical findings. This is an at-
tempt to eliminate subjective experimenter bias
in favor of an "objective" approach to the data
derived from the tests administered. However,
subjective qualification cannot be deliberately
avoided, since interpretation, to a certain extent,
is based on the interpreter's clinical acumen and
experience with making assessments based on pre-
vious and similar case histories.
Furthermore, the battery lacks grounding in a
theoretical formulation of the brain's functional
organization governing psychological processes af-
fecting behavior. Questions do not arise from
clinical neuropsychological assessments in an at-
tempt to generate research on how the .brain's
functional organization affects behavioral processes
by regulating them. Such considerations are vital
to providing clues as to (a) how the brain works
based on a functional organization, and (b) the
type of rehabilitation approaches needed after the
disturbance has been accurately assessed and
studied neuropsychologically. With the advent of
computerized axial tomography scanning (cur-
rently available in the West due to recent neuro-
AMERICAN PSYCHOLOGIST • NOVEMBER 1977• 961

4. radiological advances), brain lesions can now be
directly viewed in certain cases, photographically,
by noninvasive techniques requiring just several
minutes. What this technique poses for the future
of neuropsychologists using the Halstead-Reitan
battery is how to go about the systematic study of
different kinds of behavior involved in brain-be-
havior disturbance without a working theory or a
conceptual scheme of the functional organization
of the brain.
Soviet Approach to Clinical
Neuropsychological Investigation
During the past 40 years, Soviet scholars have par-
ticipated in the creation of a new branch of science
among the neurosciences called neuropsychology.
This discipline is primarily concerned with the
role of individual brain systems in the organiza-
tion of human psychological activities and is de-
pendent upon such sciences as neurology, psychol-
ogy, and linguistics. In the USSR, the senior
author and his co-workers have spent over 40 years
formulating the basic principles of the science of
neuropsychology. They described the symptoms
found in the lesions of the basic zones of the hu-
man brain and the principal neuropsychological
syndromes arising in localized lesions. Their start-
ing assumption is that the aim of neuropsychology
in local diagnosis of brain lesions is to analyze the
disturbances of the higher cortical processes of the
specific trait of a person's psychic activity. Quali-
fication of the deficit is of basic significance for
the neuropsychological investigator, as he must
first begin with a detailed knowledge of the given
form of psychological disturbance, for example,
perception, speech, or problem-solving (Luria,
1966b). By means of this approach, neuropsy-
chology has become an investigative tool in the
diagnosis of local brain lesions and has led to an
empirically formed theory for (a) the rehabilita-
tion of complicated functions that have been dis-
turbed by lesions and (b) the functional organiza-
tion of the brain in different blocks serving dif-
ferent psychological processes. Early investiga-
tions carried out by Soviet neuropsychologists
have demonstrated that neuropsychology is not
only important on the practical and clinical level
but that it also holds importance for the advance-
ment of a scientifically based theory about the
very structure of the neural basis of psychological
processes.
Neuropsychologists in the USSR have focused
on the study of the defective mechanisms of mem-
ory (Luria, 1976b), neurolinguistics (Luria,
1976a), etc., involved at the basis of different
brain syndromes described (Luria, 1966a, 1966b,
1973). Soviet neuropsychological research has
demonstrated conclusively that higher forms of
human psychological activity and human behav-
ioral acts take place with the participation of all
parts and levels of the brain, each of which makes
its own special contribution to the work of the
functional systems as a whole (Luria, 1970a,
1970b). In the present state of the art of clinical
neuropsychology, it has become necessary to cor-
relate the discoveries obtained by modern tech-
niques of neuroradiology with the neuropsychologi-
cal data concerning the nature of the disturbance
observed in order to put the clinical neuropsycho-
logical method on a valid foundation.
ADVANTAGES OF SOVIET METHODS
Past efforts by Soviet neuropsychologists have been
principally based on a conceptualized theory of
the functional organization of individual brain sys-
tems involved in regulating human psychological
activity. Study of brain function and psychologi-
cal processes affecting human behavior when dis-
turbed due to a localized lesion has largely been
based on the "qualitative" method of investigation
—that is, on a clinical description using a flexible
but systematic set of tests. This approach is simi-
lar to that of factor analysis, that is, breaking down
the results for further separate analysis in order to
determine those factors that show up significantly
among the variables tested. The Soviet neuropsy-
chologist's approach strongly opposed direct quan-
titative psychometrics in the past, holding to the
viewpoint that for all those functions and abilities
for which the normative standard is an average,
only an individual, single-subjects evaluation pro-
vides a meaningful basis for assessing brain deficits.
It is still held that a population average is not an
appropriate standard of comparison, since it doesn't
ordinarily apply to the case of an individual pa-
tient. All relevant clinical data are used in for-
mulating a working hypothesis of the patient's
presenting problem, in contradistinction to a
"blind" approach. It is a "dynamic," that is,
flexible, approach, in contrast to the rationale of
the Halstead-Reitan Neuropsychological Test Bat-
tery. Each patient analysis is a theoretically
based dynamic experiment on the behavioral effects
accrued from a disturbance in the brain. Several
962 • NOVEMBER 1977 • AMERICAN PSYCHOLOGIST

5. studies can be made in 30-SO-minute sessions (and
if desired, continued over time as well) to accu-
rately construct a clinical picture of the defects
and monitor any changes within the patient's be-
havior. The results can then be compared with
other cases assessed having similar syndromes or
lesions in order to obtain an intersubject com-
parison for generalization purposes.
In place of cut-off scores for assessing the degree
of the gross brain damage, its site, and its extent,
the qualitative approach affords data from which
clinical inference is used to construct a working
hypothesis from the observed facts. Hypotheses
are subject to revision if new data are obtained
affecting the clinical picture. In contrast to the
Halstead-Reitan approach of using cut-off scores, a
qualitative study is performed using an inductive
approach to the patient's syndrome. This neuro-
psychological method of study is useful in replac-
ing incorrect hypotheses with better ones accord-
ing to the data received during the neuropsycho-
logical experiment. The method generates ques-
tions for further neuropsychological analysis clini-
cally and experimentally (if desired) and aids in
providing clues for rehabilitation treatment and
planning for the patient from Soviet clinical ex-
perience. In terms of advancing a scientific ap-
proach to the science of neuropsychology, a wide
range of information can be gathered in an attempt
to construct an accurate picture of the cerebral
organization of man's brain governing behavior
and conscious action. At the same time, this ap-
proach lends itself to electrophysiological investiga-
tion of the psychological processes of the patient's
deficits, which can complement the data obtained
from both a clinical and neuropsychological in-
vestigation.
LIMITATIONS
Reitan has made the assertion (Reitan & Davison,
1974) that the Soviet approach places primary em-
phasis on the individual case study rather than on
group statistics as a source of generalizable data.
One of these authors expressed the view that in
neuropsychology, where the material is compara-
tively limited in amount, attention should be
focused on the intercorrelation of symptoms, and
quantitative analysis should be specially developed
for use in such cases. The need has been acknowl-
edged for verification of clinical data in collecting
observations of brain-behavior disturbance in
order to establish the reliability of current methods
in use. Although far from thinking that quantita-
tive measurement is the only true criterion for data
collection in science, Soviet neuropsychologists
have asserted that "the time has come for mathe-
matical analysis of the vast amount of material
gathered as a result of observations over the last
forty years, observations that lie at the basis of
neuropsychological syndromes of local brain lesions
and that give these syndromes their essential re-
liability" (Luria & Artemieva, 1970, p. 111).
Qualitative Scheme of Soviet Clinical
Investigation
It has been demonstrated from the above that
neuropsychology in the USSR follows a very differ-
ent approach than American clinical psychology
in general and American clinical neuropsychology
in particular. Soviet neuropsycholpgists start from
a theory of the human brain's functional organiza-
tion (Luria, 1970b) gained from many decades of
clinical and experimental studies (anatomical,
physiological, and psychological). They formulate
hypotheses in order to direct them as to what
might be expected in cases of lesions occurring in
different parts of the functional systems in the
brain. It has been shown that each part of the
brain's functional systems enters into the brain's
working as a whole (Luria, 1973) and provides its
own highly specific contributions. It is further
supposed that the forms of behavior under study
are very complex psychological processes that in-
clude a varied set of factors that can be disturbed
in many different ways. Symptoms evoked by dis-
turbances of different factors have complicated
structures and can have different causes. For this
reason, symptoms must be carefully analyzed and
"qualified." The "qualification of the symptom"
depends on a careful analysis of the patient's de-
fects. This is the basic goal of the Soviet neuro-
psychologist's approach. He is never content with
merely finding a certain defect—for example, a
deficit in perception, memory, action, or realization
of programs. The singling out of a symptom is
not the end but rather the beginning of his work,
which continues in depth. He attempts the elu-
cidation of the disturbed structure, attempting to
find distinct psychological factors underlying the
symptom. This must occur first, in order to make
the symptom's inner structure lucid and to allow
the formulation of a hypothesis as to its relation-
ship with a local brain lesion. Thus, the designa-
tion of the defect's general nature—for example, a
AMERICAN PSYCHOLOGIST • NOVEMBER 1977 • 963

6. perceptual, memory, or vocabulary deficit—is not
the end of psychological assessment but rather the
initiation of a thorough line of investigation into
its many aspects.
The logical route for the neuropsychologist to
take in his approach to the above task is as fol-
lows. If the "symptom" under observation is seen
as the result of a breakdown in a certain factor
involved in a psychological system, then related
forms of behavior that can include this factor be-
come disturbed, while other forms of activities in
which this factor is not included remain intact.
Soviet neuropsychologists use a detailed yet dy-
namic (i.e., flexible), investigative approach, ap-
plying different tests appropriately addressed to
the different aspects of behavior. In each in-
stance, subsequent data obtained are compared
with the baseline data in an attempt to find a
"common element" underlying the different kinds
of symptoms that are manifested in varied forms
in the patient's behavior.
The qualification of a symptom, seen in the
above light, is thus a series of replications and a
study of the results obtained that requires a cer-
tain degree of flexibility in the investigator's think-
ing, concomitant with a critical capacity for reject-
ing hypotheses not supported by the data. Only
when a group of symptoms pointing to a common
factor is discovered, and when a syndrome verified
on the basis of reliability confirms the hypothesis,
does the work of the neuropsychologist come to
the point at which a true picture can be estab-
lished.
Qualification of a symptom is never construed
as the mechanistic application of a standardized
test battery with formal quantitative interpretation
of the results. In contradistinction, it is a clini-
cally creative effort requiring from the neuropsy-
chologist both critical thinking and readiness to
reject initial hypotheses if they conflict with new
data obtained or if there is confounding of re-
sults. Soviet neuropsychologists use as their start-
ing point a general scheme in their investigations.
This scheme includes, first of all, a carefully de-
tailed interview with the patient. Questions are
asked about his complaints. Exaggerated com-
plaints are as important as the absence of com-
plaints. The first can be either a patient's com-
pensatory reaction to his defect or a symptom of
overexcitation of the basal and mesial structures
of the brain, whereas the second can very often be
seen as a symptom of frontal lobe deficits in the
critical evaluation by the patient of his own de-
fects. Another possibility raised is the symptom
of anosognosia, typically observed in lesions of
the minor hemisphere.
Complaints of headaches (if not associated with
local pain during percussion of a control zone of
the cranium) are of rather restricted value for the
local diagnosis of brain injury. The same can be
said about general complaints of bad memory—
that is, they are very often observed and, as one
witty psychiatrist used to say, "Everybody com-
plains of a loss in memory, but hardly anybody
complains of a loss of intelligence." Complaints of
memory loss evoke questions of what "kind" of
memory deficits the patient exhibits. General or
modality-specific? Are the deficits due to patho-
logical "blocking" of traces by interference or due
to a "trace decay"? The same applies to com-
plaints of increased difficulty in problem-solving
ability. Is it due to a trace decay? To an inabil-
ity to convert the successive information in simul-
taneous—often spatial or quasi-spatial—schemes?
To a pathologically "increased inertia" of the men-
tal processes?
Perhaps one of the greatest values in obtaining
a complete history is the descriptions given of the
areas preceding the disturbances, for example,
acoustic or visual, tactual or visceral, as well as
complaints of defects in vision, for example, symp-
toms of hemianopia (although patients seldom use
the phrase "restricted vision on one side," prefer-
ring to talk about "bad vision of the left or the right
eye"). Of supreme value are the patient's answers
to questions of hie et nunc: What is the date, the
hour, or the place where he is? Has he already
had a meal? What did he do yesterday? etc.
Every defect in answers to such questions can
yield valuable information about the patient's state
of consciousness and his orientation in space, time,
and place, which very often are closely associated
with pathological processes in the deep structures
of the brain.
In each case, the neuropsychologist ought to give
particular attention not only to the content of the
answers produced but to their form. It should al-
ways be kept uppermost in the mind that the kind
of answers received are important with regard to
the forms of the patient's behavior. Examples of
quick or impulsive answers (with or without cor-
rections), echolalic repetitions of the question, or
an inability to answer when the question requires a
preliminary choice between several alternatives can
be observed.
The scheme of clinical investigation also includes
964 • NOVEMBER 1977 • AMERICAN PSYCHOLOGIST

7. analysis of deficits in praxis (motor action), gnosis
(optic, acoustic, and cutaneous as well as postural
perception), memory (modality-specific or general,
nonverbal and verbal mnestic processes), speech
(generation of utterances and their understanding,
including writing and reading), and problem-solv-
ing behavior.
An important underlying principle stressed dur-
ing the investigation is this: The symptoms we ob-
serve are simple and do not present any difficulties
in intact, persons. For this reason, we pay atten-
tion not only to the patient's inability to solve a
given problem (or the presence, absence, or level
of the defects), but foremost to the kind of defect,
and last but not least, to the factors that underlie
the symptom. Maximum stress should be placed
not so much on what suffers but rather on how a
function suffers. This is the essence of what is
meant by the term qualification of the symptoms,
previously mentioned.
After the preliminary interview is completed, we
begin our formal investigation by trying to see
whether the patient has difficulties in praxis. He
is asked to imitate movements or some posture of
the examiner's hand. For example, a modeled
posture of the index and little fingers of the right
hand stretched out is presented, and the patient
must imitate this posture with his own right hand.
An inability to do this raises a number of different
questions with quite different implications neuro-
psychologically. The patient can show difficulties
in producing the necessary positions of the fingers
and perhaps succeeds only after several trials,
sometimes using his other hand to help position his
fingers. The source of such defects might lie in a
disturbance of the afferent organization of the
movement, that is, in a breakdown of the appropri-
ate communication of impulses associated with a
defect in the sensory impulses of joints and mus-
cles. This might then suggest that a lesion in the
postcentral parts of the hemisphere (contralateral
or the major one) is the site where the defect
originates.
The inability to reproduce the correct posture
presented can have other sources as well. It can
stem from the inability to overcome an immediate
mirroring effect, which produces a "crossed" reac-
tion, that is, an immediate imitation of the ex-
aminer's movement by stretching forward the little
finger of the right hand when the examiner's right-
hand index finger is shown. This error might sug-
gest that the defect is one of spatial analysis or of
coded action that is replaced by a simplistic, imita-
tive reaction. In the former example, the parieto-
occipital region is involved, and in the second
"echopractic" example, a frontal defect could likely
be the area of involvement.
Other difficulties arise in attempting to resolve
this simple problem. Having reproduced one
posture, the patient, for example, may then be un-
able to shift from the movement given. In our
work, we term this pathological inertness. Diffi-
culties such as this can be the result of pathological
perseveration of the movement. In such cases, the
symptom is one of a quite different nature than
previously considered. We can hypothesize that
perhaps some pathological processes of the anterior
parts of the hemispheres are involved.
If we have inferred from the above initial ob-
servation that defects of complex hand movement
are due to difficulties in kinesthetic afferent ac-
tivity in the first of a series of experiments, we then
move on to a series of other tests that include
movements for which complex kinesthetic activity
is not required. Instead, the spatial organization
of movements is required. One such example of
motor action is a test in which a simple movement
of the patient's hand has to be oriented in space;
the patient must put his palm in a horizontal,
frontal, or sagittal position. Another example
using a more complex test (Head's Test) requires
the patient (sitting vis-a-vis the examiner) to re-
produce some complicated movements, for example,
lifting the right hand when the examiner lifts his
right or lifting the left hand when the examiner
lifts his left.
If the patient fails these tests, and if a break-
down in optico-spatial processes is suspected on
medical grounds as the source of the defect, then
the next step is to examine how far the patient can
go in problem solving that requires the use of
inner coding schemes or quasi-spatial schemes at
the symbolic level. Difficulties in evaluating the
positions of the hands of a watch, in determining
the relations of directions on a geographical map,
or even in computing and decoding some complex
logico-grammatical constructions (e.g., "a circle
under the triangle," "brother's father," and/or
"father's brother") can yield additional informa-
tion concerning the derangements of simultaneous
spatial (or quasi-spatial) neural schemes usually
associated with injuries of the infero-parietal
parts of the major hemisphere. If the patient is
able to overcome the tendency of "mirroring"
movements (reproduction of the position of the
examiner's hands) or if there are no sustained de-
AMERICAN PSYCHOLOGIST • NOVEMBER 1977 • 965

8. fects in the tests just mentioned, one can surmise
that defects in spatial analysis (associated with the
parieto-occipital parts of the brain's cortex) are
absent and that the tendency to give an immediate
imitation has another basis and is perhaps associ-
ated with lesions of the frontal lobes of the brain.
However, this does not yet exhaust our investi-
gation, since we cannot yet accept the hypothesis
that the factor of kinesthetic afferent activity is
the only source of the patient's underlying defec-
tive movement. Nor can we conclude, positively,
that these defects are associated with a lesion of
the postcentral area of the cortex. Another pos-
sibility needing to be eliminated is the origin of
this motor defect arising from its organization in
time—for example, from pathological inertia of the
neural processes due to a lesion in the frontal or
premotor zones of the brain.
Moving further into our neuropsychological con-
sideration of the symptoms being observed, in
order to confirm or disconfirm our original hy-
pothesis, we must turn to another set of experi-
ments designed to study the "plasticity" of the pa-
tient's behavioral processes. Here we must con-
sider eliminating the kinesthetic or the visuo-
spatial complexity of the movements involved and
must present the patient with sequential organiza-
tion of his actions, for example, with tasks where
only the "plasticity" or "inertness" of his actions
is demonstrable. For example, the patient may
be asked to reproduce the examiner's tapping
rhythm and to shift from tapping by twos to tap-
ping by threes or from such simple tapping to
more complex tapping (e.g., two taps loud, three
taps soft, and then reversed). He is then asked to
return once more to the simple patterns of tapping
(by twos or threes). If his neural processes show
signs of pathological inertia, this simple test be-
comes difficult and the patient is unable to shift
readily from tapping by twos to tapping by threes.
Defects in this test of serial organization of
movements can lead to the hypothesis that "dy-
namic" factors or defects in "plasticity" can be
the source of the disturbances observed in the first
test.
To continue study of the persistence of the ob-
served inertia, still another test can be used. In
this test, the patient is asked to draw a circle first,
then a cross, and then a triangle (or, in more
thorough tests, a circle, cross, triangle, square,
etc.). In each trial there is a shifting from one
pattern to another. If flexibility of actions is dis-
turbed, one of the following difficulties arises. The
patient either continues the movement started and
repetitively produces a circular movement (which
is often the case observed in massive or deep
frontal tumors) or he perhaps fulfills the first in-
struction but shows difficulties in transition to the
next trial. Once a circle is drawn, he might con-
tinue drawing a circle, perseveratively, even when
asked to draw a cross. Or, in drawing two figures,
a circle and a cross, the patient may start to draw
a cross but then revert to preserving features of
a circle, drawing and including mixed features of
a cross and a circle.
More complex forms of pathological inertia can
be seen in the actualization of complex instruc-
tions when, after the first instruction is completed,
the patient shows a perseverative tendency in the
realization of the second instruction.
If we wish to confirm or disconfirm our hypoth-
esis as to the lack of plasticity of other parts of
the patient's nervous system (as to their personal
integrity in conjunction with the symptoms under
study), we can follow one of two further direc-
tions: either continue in the vein of studying
motor behavior or look at other variables that
might play a role in the clinical picture.
The first of these suggested directions involves
moving on to a study of more complex forms of
motor behavior under conditions requiring a break-
down of "imitative" tendencies and stereotypes by
the patient. For example, the patient may be
asked not to imitate the examiner's postures but to
obey some verbal instruction completely contra-
dictory to his immediate impression (e.g., show a
finger when a fist is shown, or vice versa, make a
quick, sudden, intense movement when a soft stim-
ulus is presented).
The second direction can be taken once a stereo-
type of motor reaction is established. The in-
struction to react with the movement of the right
hand to one sound and with the movement of the
left hand to two sounds leads to a stereotyped
right-left-right-left movement. If this instruction
is repeated, the examiner can then break this
stereotype and unexpectedly present another series,
for example, right-left-right-left-left. The appear-
ance of imitative movements in the first example of
stereotyped reactions, where the patient neglects
the instruction and continues the learned set (the
right-left-right-left series), leads to the suggestion
that a breakdown of the controlling function ,of
speech is present and that a disturbance of the
frontal lobes is very probable.
In all of the previously considered examples,
966 • NOVEMBER 1977 • AMERICAN PSYCHOLOGIST

9. similar symptoms of pathological inertia can be
seen in more complicated verbal or symbolic forms
of behavior.
There are two tests particularly appropriate to
demonstrating the potential plasticity observable
in the patient's psychological processes during dis-
turbances. The first test deals with verbal mem-
ory and the second with mental arithmetic com-
putation.
In the first test, imparting words to verbal mem-
ory, three words are presented to the patient. He
is then asked to repeat the series. A second group
of three words is subsequently presented. After
this second group is repeated by the patient, he is
asked to retrieve the first series of words and then
the second. A -breakdown in the psychological
system of plasticity and a tendency toward per-
severation can be observed if such disturbances
lead to either of these results. The patient with a
tendency toward "inertness" of mental processes
can show marked difficulties in the retrieval of the
first series of words after the second series has
been presented and repeated by him. In many in-
stances, it has been observed that words from the
second group show up due to pathological inertia
and that the patient includes them in the repetition
of the first group of words. In cases of massive
frontal lobe lesions, even a repetition of the second
series may likely be impossible and may be re-
placed by an inert repetition of the first series. In
mild cases of injuries to the frontal lobes, this ob-
served inertia is clearly seen in retrieval of the
previous series of independent words. Compared
to massive frontal lesions (bifrontal tumors or
trauma of both frontal lobes), this is not the case;
retrieval of the first group of organized phrases or
texts after the second series is presented becomes
an impossible task. The patient continues to re-
produce the second phrase or includes some inert
part of the first. Contamination due to inertness
of the higher cortical processes can be clearly ob-
served. The same phenomenon can be seen if we
ask the patient to count backward, arithmetically,
or to name months of the year in reverse order. If
no signs of pathological inertia are present, both
tasks are easily completed.
Summary
The basic approaches to neuropsychology in the
United States and the USSR differ both in primary
orientation—the former being quantitative and the
latter, qualitative—and in theoretical foundation—
a working theory of brain function in relation to
behavior provided by the latter versus no theory
at all in the former. Both the American and
Soviet methods have proven useful in the diagnosis
of brain-behavior disturbances. The Soviet method
oi investigation has provided insights in the on-
going study of brain-behavior relationships both
pie- and postoperatively; it has provided fruitful
direction in approaches toward restoration of de-
fective functions and in rehabilitation planning;
and it has yielded a systematic conceptualization of
the brain as a group of functionally organized
"blocks" governing the regulation of psychological
processes. It has generated questions and has led
to electrophysiological research investigations into
the physiological bases of disturbed psychological
functions due to brain disturbances. While cur-
rent Soviet methods need to be verified through
cross-validation in order to accurately assess their
reliability, it seems that the necessary and logical
first steps in any new science are (a) to collect data
accurately, (b) to formulate hypotheses from ob-
servations and to confirm correct ones, and (c) to
make numerous adequate tests through repeated
experiments before subjecting the results of the
methods to statistical scrutiny.
Soviet investigation does not end when a symp-
tom's presence is demonstrated and confirmed.
Rather, a description of the symptom is first given,
which leads to the next essential step of qualifying
it in an effort to detect its sources and to single
out the underlying psychological factors affecting
the psychological processes (and to establish a
picture of the syndrome that can confirm the initial
hypothesis). The emphasis of this detailed, qual-
itative, clinical analysis is how the brain's func-
tioning is disturbed. This approach is similar to
that of "analysis-by-synthesis," which can lead to
reliability of results when using a single-subjects
experimental or clinical design. Used in this man-
n<;r, over subject populations with the same clas-
sifications of pathology, it can yield reliability as-
sessed through the syndromes obtained and valid-
ity based on intersubject data.
A purely quantitative approach to the measure-
ment of brain disturbance of behavior that uses a
test battery with a cut-off score as a performance
ciiterion is insufficient to yield rich data for a
comprehensive neuropsychological interpretation.
The blind method of interpretation of standardized
tests without prior knowledge of the patient's his-
tory and clinical test data can hardly serve in
providing a complete and sound analysis for the
AMERICAN PSYCHOLOGIST • NOVEMBER 1977 • 967

10. diagnosis of brain lesions and for treatment recom-
mendations. This especially holds true for the
young psychologist lacking a wide enough back-
ground and experience with neuropsychological in-
terpretation.
Some areas that have recently been given at-
tention by Soviet neuropsychologists are as fol-
lows: (a) neurolinguistics, (b) human develop-
mental processes (in a child's brain), (c) right-
hemisphere functional activity, and (d) the neuro-
psychology of memory mechanisms. Work in our
Moscow laboratory has been underway for the
last 15 years in the above areas. If neuropsychol-
ogy is to flourish as a science in the future, further
baseline data consisting of recorded clinical and ex-
perimental observations, as well as anatomical and
electrophysiological data, are needed. Important
questions needing answers are as follows: How
does the brain effect control over its ownbehavior?
How does it make a decision to behave the way it
does during certain psychological activities? How
is the brain able to compensate when partially (or
fully) arrested in functions by a brain tumor?
How does an infant brain develop into a fully in-
tact adult one? The senior author has spent over
40 years pioneering new frontiers, adding insights
into some of these areas, and posing questions, all
of which have led to a model of the working brain
based on functionally organized blocks. It is now
the task of future generations of neuropsychologists
to replicate this work, to expand upon how the
psychological and physiological processes are in-
volved in the working brain for a better scientific
understanding of brain-behavior activity, and
hopefully, to prevent or treat brain-behavior dis-
turbances wheneverpossible.
REFERENCE NOTE
1. Adams, K., Rennick, P., & Rosenbaum, G. Automated
interpretation of the neuropsychological battery: An
ability-based approach. Paper presented at the meeting
of the International Neuropsychological Society, Tampa,
Florida, February 1975.
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