Академический Документы
Профессиональный Документы
Культура Документы
0887-6177(95)00015-1
A methodology to assist in distinguishing deficient memory storage from comproraised retrieval operations is presented for use with the Logical Memory (LM) and
Visual Reproduction (VR) subtests of the Wechsler Memory Scale - - Revised
(WMS-R; Wechsler, 1987). A 21-item five-option multiple choice recognition test
for LM and a cuing teclmique for VR are presented, followed by descriptive data
based on a sample of 94 psychiatric inpatients (mixed diagnoses) and a sample of
99 brain-injured (BI) patients. The B! sample performed worse than the psychiatric
sample on all of the LM and VR measures, with VR-CUED showing the highest
degree of discrimination. In both groups, many subjects initially acquired much
more information than they reported during the standard free recall format. The
supplemental scoring format and reference data reported herein provide clinically
useful information regarding a person's ability to store and access new information.
476
C. S. Gass
effectiveness of retrieval processes in accessing stored information. From a diagnostic standpoint, this distinction is important inasmuch as certain neuropathologic disorders, such as Alzheimer's disease and Wemicke-Korsakoff's Syndrome,
are associated with a prominent encoding deficit (Cermak & Butters, 1972),
whereas other disorders that involve subcortical disease (e.g., early Huntington's
disease or multiple sclerosis) or damage localized to the prefrontal area appear to
be associated with a prominent retrieval deficit and relatively spared encoding
capacity (Albert, Butters, & Brandt, 1981; Butters, Wolfe, Martone, Granholm, &
Cermak, 1986; Rao, 1986). Psychiatric disorders, such as depression, have also
been associated with a prominent retrieval deficit. For example, studies have supported the view that depressed individuals sometimes exhibit deficient free recall
performance because of a conservative response bias and/or low motivation
(Calev & Erwin, 1985; Weingartner & Silberman, 1982). Treatment implications
also exist. For example, to the extent that memory problems involve a prominent
retrieval deficit, one is more likely to benefit from cuing and from an environment
in which cues are made available to facilitate the recall of stored information.
When used alone, measures of free recall fail to reveal whether poor performance is due to an encoding defect or to failed retrieval operations. For this
reason, more recently devised clinical measures of memory and new learning,
such as the California Verbal Learning Test (Delis, Kramer, Kaplan, & Ober,
1987) include cuing and recognition testing following a delayed free recall
trial. The joint use of free recall and cuing and/or recognition test formats
assists in assessing the relative efficacy of encoding and retrieval processes.
Although these processes cannot be fully distinguished using behavioral measures (e.g., retrieval success is partly dependent on the quality of encoding), in
general, successful storage of information is indicated by a high recognition
(or cued) score, regardless of free recall performance, and effective encoding
and retrieval operations are indicated by a high score on delayed free recall.
Unfortunately, some widely used measures, such as the Logical Memory (LM)
and Visual Reproduction (VR) subtests of the Wechsler Memory Scale - Revised (WMS-R), provide scores only on free recall and lack a measure that
assesses memory storage in a precise manner (Butters et al., 1988). This problem was addressed in relation to the original WMS by Kaplan and her colleagues (Milberg, Hebben, & Kaplan, 1986). This article presents a method of
recognition testing using the LM subtest of the WMS-R. In addition, a cued
recall format for scoring the VR of the WMS-R is also recommended to assist
in the assessment of encoding and retrieval of visuographic information.
METHOD
Subjects and Procedures
477
sample, selected from amongst referrals made during the previous 5 years,
included 94 psychiatric inpatients who were diagnosed with emotional disorders and did not have any history of neurologic disease or positive test findings
on routinely administered CT scan and, in some cases, MRI and EEG. In order
to address the potential relation of emotional disturbance to memory performance without the confound of structural brain damage, patients were excluded if they had a history of head trauma involving loss of consciousness or any
other evidence of cerebral pathology. Diagnoses as established by staff psychiatrists using DSM-III-R criteria included major depression (n = 43), bipolar
(n = 12), generalized anxiety (n = 8), PTSD (n = 17), and other (n = 14). The
remaining 99 patients had neurologic diagnoses of traumatic brain injury
(n = 54) and stroke (n = 45), as concluded by staff neurologists using CT, MRI,
and other procedures deemed necessary. These two neurodiagnostic groups
were selected because of their high incidence in both the V.A. and the general
population. Patients who had other common but severely debilitating conditions, such as Alzheimer's disease, or who were unable to complete the entire
test battery (which included the Halstead-Reitan battery), were excluded from
this study. The psychiatric sample had a mean age of 49 years (SD = 13), education of 12.7 years (SD = 2.4), Full Scale IQ of 99.6 (SD = 13.8), and
Average Impairment Rating within the normal range, 9.82 (SD = .44). 1 The
brain-injured (BI) sample had a mean age of 52 years (SD = 15), education of
12 years (SD = 3.0), Full Scale IQ of 89.6 (SD = 11.8), and Average
Impairment Rating within the borderline impaired range, 9.20 (SD = .71). The
number of BI patients within each impairment range on the AIR was: 8 (moderate), 28 (mild), 35 (borderline), and 28 (minimal or none). 2
Subjects were administered the immediate and delayed (30-min) formats of
the LM and VR subtests of the WMS-R, along with two follow-up measures
described below, as a routine part of a standard neuropsychological battery
administration. Scoring was performed by trained examiners using the criteria
outlined in the manual. In addition, a Percentage Retained score was computed
to examine half-hour retention efficiency relative to performance on immediate recall (Russell, 1975).
478
C. S. Gass
based on the two stories (Appendix 1). Items were constructed to include one
correct response option and four alternative (incorrect) options, yielding a
level of random or chance-level responding of 20%. The patients were administered this questionnaire immediately after completing the delayed free recall
administration of the LM subtest (LM 11).3 The instructions, which are provided on the test form, were read aloud to each patient. In order to ensure that the
instructions were understood and could be followed, each patient was further
instructed to read and respond to the first item aloud and to mark the answer
on the questionnaire form. In a small number of cases involving reading difficulties, the examiner read and repeated each item to the patient. The instructions encourage the examinee to guess when uncertain.
Recognition was assessed in order to determine how much information the
examinee effectively stored in memory but may have been unable to retrieve in
the delayed free recall format. The scoring procedure required counting the
number o f correct items (range of 0-21). An estimate of the incremental benefit derived from recognition could subsequently be made by contrasting performance on L M - I I free recall with performance on L M - R E C . Scale scores,
described below, were derived to assist in this task.
479
stop me as soon as you think that you may recall the design. At that point
I will let you complete it. The important point is that I want to see how
much you can remember.
The examiner, using a pencil of a different color than that used by the
examinee, then very slowly drew the missing design(s) following the standardized procedures below, b e g i n n i n g with the earliest design in the
sequence. Design one was drawn beginning with the top right-side of the
diagonal and drawing downward. This was followed, if necessary, by the
second diagonal, again starting at the top. Design two was initiated with the
larger of the three circles, followed by the second largest circle. Design
three was started with the upper segment of the large square, drawing left to
right, then completing the square in a clockwise manner if necessary. This
was followed by drawing its two intersecting vertical and horizontal lines.
The last design was initiated in a similar manner, starting with the largest
rectangle, followed by the upper, and finally the lower of the two smaller
rectangles. If the right side of design four was omitted, either on free recall
or after cuing the left side (rectangles), it was cued beginning with the
curved portion of the half circle and followed, if necessary, by the straight
vertical line. No direct cuing was performed on the small triangle attached
to the semicircle.
Scoring of cued VR recall was based on the same criteria that the WMS-R
manual applies to scoring free recall. However, points were not allotted for
any criteria that were reached or otherwise given away by the examiner in
the cuing process. For example, no credit was given to the examinee for
completing a circle, square, or rectangle that was partially drawn by the
examiner. Only the examinee's portion of the cued drawing was scored, and
this was easily observed by noting the color of the examinee's production.
Also, credit was not given to the examinee for symmetrically duplicating
(mirroring) the examiner's drawings of the flags in design 1, or the inner
detail of the quadrants in design 3. The rationale for these criteria is that the
score should only reflect what the examinee can reproduce from memory.
The incremental benefit derived from cuing can be estimated by scoring VR
twice, with and without cuing, and examining the difference. As with LMREC, scale scores are useful in quantifying the difference vis-a-vis a normative sample.
RESULTS
480
C. S. Gass
TABLE 1
Mean Differences in Age, Education, and Memory Test Performance Between the
Psychiatric and Brain-Injured Patients
Psychiatric
Mean
Age
Education
WAIS-R FSIQ
AIR
LM (Overall)
LM-I (Immediate)
LM-II (Delayed)
LM Percent Retained
LM Recognition
VR (Overall)
VR-I (Immediate)
VR-II (Delayed)
VR Percent Retained
VR Delayed with Cue
SD
Brain-Injured
Mean
SD
1.271
3.17 a
27.15 a
42.81 a
4.73 b
6.80 a
2.65 a
7.14 a
10.68 a
8.12 b
20.40 a
22.91 a
18.84 a
26.62 c
.26
.08
.000001
.000001
.001
.01
.001
.00005
.001
.00001
.0000 I
.0002
.01
.000001
49.6
12.7
99.6
9.83
13.0
2.4
13.8
0.44
51.9
12.0
89.6
9.20
15.4
3.0
11.9
.71
20.4
16.2
76.4
16.4
6.9
7.8
20.1
2.9
17.4
11.9
61.3
14.7
8.3
8.41
28.91
4.1
30.5
23.9
77.3
26.4
6.2
9.3
19.9
8.3
25.4
16.9
61.2
19.1
8.7
11.2
29.1
10.8
Note. AIR = Average Impairment Rating, LM = WMS-R Logical Memory, VR = WMS-R Visual
Reproduction.
adf= 1,191.
bdf= 4, 188.
cCued patients only, n = 109, df= 1,107.
481
TABLE 2
<55
55-65
66-75
<12
12-14
>14
+2
0
-2
+3
+1
-1
+4
+2
0
482
C. S. Gass
TABLE 3
Scale Scores for the LM-II a a d LM-REC
Raw Score
Scale
11.2
11.0
10.7
10.5
10.2
10.0
9.7
9.5
9.2
9.0
LM-H
26
25
23
21
20
18
16
15
13
12
Raw Score
LM-REC
Scale
LM-H
8.7
8.5
8.2
8.0
7.7
7.5
7.2
7.0
6.7
10
13
--
7
5
3
2
--0
12
11
10
-9
8
7
21
20
-19
18
17
-16
15
14
LM-REC
DISCUSSION
T h e a d d i t i o n o f r e c o g n i t i o n a n d c u i n g f o r m a t s for t h e W M S - R L M a n d V R
subtests, respectively, r e q u i r e s v e r y little a d m i n i s t r a t i v e t i m e a n d c a n p r o v i d e
TABLE 4
Raw Score
Scale
LM-II
LM-REC
Scale
LM-II
LM-REC
11.2
40
I1.0
10.7
10.5
10.2
10.0
9.7
9.5
9.2
9.0
38
35
33
30
28
25
23
20
18
38
36
34
32
30
28
25
24
21
19
8.7
8.5
8.2
8.0
7.7
7.5
7.2
7.0
6.7
15
13
10
8
5
3
1
-0
17
15
13
11
8
7
4
2
0
483
clinically useful information regarding information storage and retrieval processes. In particular, the contrast between the standard free recall scores and
recognition or cued-enhanced scores may be useful in determining whether an
individual's poor performance is due to problems with information storage,
retrieval difficulties, or both. The current findings suggest that many examinees, including emotionally disturbed and neurologically compromised persons,
probably acquire substantially more information than may be implied by measures of free recall. This is consistent with the fact that people commonly recognize or, when prompted by a cue, retrieve, substantially more information from
memory than would be suggested by the use of a free recall methodology.
Performance on memory tests, including the LM and VR subtests of the
WMS-R, is, as a general rule, more adversely affected by brain damage than by
emotional disturbance (Gass & Russell, 1986; Lachner, Satzger, & Engel, 1993).
In this study, the brain-injured sample had relatively mild impairment, yet manifested consistently poorer performance across the memory measures than that
shown by the psychiatric sample. However, on most measures, the magnitude of
the difference averaged about one-half of a standard deviation. The Visual
Reproduction measures showed general superiority over Logical Memory in discriminating between the BI and psychiatric samples, perhaps because VR
requires graphomotor and visuospatial ability in addition to memory. Amongst
the LM measures, the savings score (percent retained) was the best discriminator, whereas amongst the VR indices VR-CUED showed the highest degree of
discrimination between the two groups. Immediate recall of LM was the weakest discriminator of all of the measures. It should be emphasized that these findings, based on the samples described, may not generalize to patient groups that
are comprised of patients who have other diagnoses (e.g., schizophrenia,
Alzheimer's disease) or differing levels of cognitive impairment. In addition,
because the present findings are based on a select population, descriptive data
derived from the application of these procedures to other samples (e.g., normals,
psychiatric outpatients, and other diagnostic groups) would be clinically useful.
Recent decades have witnessed a significant amount of scientific progress
in uncovering some of the neural circuitry involved in the storage of information. An area that requires further study concerns the extent to which emotional, motivational, and physiological factors affect the capacity to store and to
access information. In view of the popularity of the WMS-R, the usefulness of
these supplemental procedures in characterizing various types of neurologic
disease, psychological disturbances, and malingering warrants investigation.
REFERENCES
Albert, M. S., Butters, N., & Brandt, J. (1981). Developmentof remote memory loss in patients
with Huntington'sdisease. Journal of Clinical Neuropsychology, 3, I- 12.
Butters, N., Salmon, D. P., Cullum, C. M., Cairns, P., Troster, A. 1., Jacobs, D., Moss, M., &
Cermak, L. S. (1988). Differentiationof amnesic and demented patients with the Wechsler
MemoryScale-- Revised.Clinical Neuropsychologist, 2, 133-148.
484
C. S. Gass
Butters, N., Wolfe, J., Martone, M., Granholm, E., & Cermak, L. (1986). Memory disorders associated with Huntington's disease: Verbal recall, verbal recognition, and procedural memory.
Neuropsychologia, 23, 729-743.
Calev, A., & Erwin, P. (1985). Recall and recognition in depressives: Use of matched tests. British
Journal of Clinical Psychology, 24, 127-128.
Cermak, L., & Butters, N. (1972). The role of interference and encoding in the short-term memory
deficits of Korsakoff's patients. Neuropsychologia, 10, 89-96.
Dells, D. C., Kramer, J., H., Kaplan, E., & Ober, B. A. (1987). California Verbal Learning Test.
New York: Psychological Corporation.
Gass, C. S., & Russell, E. W. (1986). Differential impact of brain damage and depression on memory test performance. Journal of Consulting & ClinicalPsychology, 54, 261-263.
Lachner, G., Satzger, W., & Engel, R. R. (1993). Verbal memory tests in the differential diagnosis of
depression and dementia: Discriminative power of seven test variations. Archives of Clinical
Neuropsychology, 9, 1-13.
Milberg, W. P., Hebben, N., & Kaplan, E. (1986). The Boston process approach to neuropsychological assessment. In I. Grant & K. M. Adams (Eds.), Neuropsychiatric disorders (pp. 65-86).
New York: Oxford University Press.
Rao, S. (1986). Neuropsychology of Multiple Sclerosis: A critical review. Journal of Clinical and
Experimental Neuropsychology, 8, 503-542.
Russell, E. W. (1975). A multiple scoring method for assessment of complex memory functions.
Journal of Consulting & Clinical Psychology, 43, 800-809.
Russell, E. W. (1981). The pathology and clinical examination of memory. In S. B. Filskov & T. J.
Boll (Eds.), Handbook of clinical neuropsychology (Vol. 1, pp. 287-319). New York: John
Wiley and Sons.
Russell, E. W. (1987). A reference scale method for constructing neuropsychological test batteries.
Journal of Clinical & ExperimentalNeuropsychology, 9, 376-392.
Russell, E. W. (1988). Renorming Russell's version of the Wechsler Memory Scale. Journal of
Clinical and Experimental Neuropsychology, 10, 235-249.
Wechsler, D. (1987). WMS-R: WechslerMemoryScale -- RevisedManuat New York: Psychological
Corporation.
Weingartner, H., & Siiberman, E. (1982). Models of cognitive impairment: Cognitive changes in
depression. PsychopharmacologyBulletin, 18, 42-47.
APPENDIX 1
WMS-R Logical Memory Recognition Test
DATE
AM PM
E a r l i e r y o u h e a r d t w o s t o r i e s t h a t y o u w e r e a s k e d to m e m o r i z e . R e a d e a c h
s t a t e m e n t b e l o w a n d c h e c k t h e a n s w e r t h a t b e s t fits t h e s t o r i e s y o u h e a r d .
M a k e sure to r e a d all t h e o p t i o n s b e f o r e y o u g i v e y o u r answer. I f y o u a r e n o t
sure, take a g u e s s a n y w a y .
485
486
C. S. Gass
STORY 2
11. The main character in the second story was
Bob Milner
Captain Jack
Robert Miller
Jan Thompson
Rod Mills
12. This person was
driving a taxi
fishing
driving a truck
riding a bus
going to school
13. The story took place in
New Orleans
Mississippi Delta
Rocky mountains
Massachusetts
a small town
14. The main thing that happened was
he left to go on vacation
he lost his money
he won a contest
he fell and hurt himself
he ran off the road
487