Constructional Abilities in Persons with Chronic ...

Constructional Abilities

in Persons

with Chronic Schizophrenia

Sharon A. Cermak, EdD, OTR

Marilyn Eimon, OTR/L

Perry Eimon, PhD

Alison Hartwell, OTR

ABSTRACT. This study was designed to examine the perfonnance

of patients with chronic schizophrenia on a series of tasks of con structional abilities. Sixteen male patients and 18 nonnal controls between the ages of 30 and 60 participated in the study. The three constructionals tests - Drawing to command and to copy, stick con struction from copying and from a memory, and a three dimensional blocks task-were drawn from the Parietal Lobe Battery (Goodglass & Kaplan, 1972). The hypothesis that patients with schizophrenia would perfonn sIgnificantly more poorly than controls was partially supported in that there were between group differences on most but not all tasks. On the Sticks and Drawing task, there was no difference between groups when the task required direct copying yet patients with schizophrenia perfonned si~nificantly more poorly than controls on the verbal command conditIon of the drawing task and the memory condition of the sticks task. On the Blocks test, patients with schizoSharon A. Cermak is Associate Professor of Occupational Therapy, Boston University, Sargent College, 635 Commonwealth Avenue, 5th Floor, Boston, MA 02215. Marilyn Eimon is Staff Occupational Therapist, BrocktonlWest Roxbury Vet erans Administration Medical Center, Brockton, MA 0240l. Perry Eimon is Coordinator, Neuropsychology, BrocktonlWest Roxbury Vet erans Administration Medical Center, Department of Psychiatry, Harvard Medi cal School, Brockton, MA 0240l. Alison Hartwell is Staff Occupational Therapist, BrocktonlWest Roxbury Vet erans Administration Medical Center, Brockton, MA 02401. Occupational Therapy in Mental Health, Vol. 11(4) 1991 © 1991 by The Haworth Press, Inc. All rights reserved.

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OCCUPATIONAL THERAPY IN MENTAL HEALTH

phrenia were significantly less accurate than controls and took sig nificantly longer than controls. Results were discussed in terms of task complexity and brain behavior relationships. The need to examine the relation of perfor mance on constructional tasks to functional performance and/or out come in schizophrenia was emphasized.

In this study, the constructional abilities of patients with chronic schizophrenia were investigated in order to determine whether an assessment of this nature is appropriate to incorporate into a stan dard occupational therapy evaluation procedure with this patient population. Occupational therapists have studied perceptual and perceptual motor deficits in a variety of different clinical populations (Ander son & Choy, 1970; Eimon, Eimon, & Cermak, 1983; Endler & Eimon, 1978; Kaplan & Hier, 1982; Niestadt, 1988; Taylor, 1968). Performance on perceptual and perceptual-motor tasks is of particu lar importance since deficits in these areas have been shown to re late to impaired functional performance in job skills and in activities of daily living, and the degree of perceptual deficits has also been shown to relate to prognosis for rehabilitation in certain brain dam aged patient populations (Bradley, 1982; Carter, Oliveira, Du ponte, & Lynch, 1988; Kaplan & Hier, 1982; Pehoski, 1970; Sivak, Olson, Kerman, Won, & Henson, 1981; Warren, 1981). The presence of perceptual deficits in the patient with schizo phrenia has only been minimally addressed since most researchers have focused on the language deficits of this population. A major line of research has emphasized selective left hemisphere impair ment in schizophrenics (Connolly, Gruzelier, Kleinman, & Hirsch, 1979; Flor-Henry, 1976; Flor-Henry & Gruzelier, 1983; Flor-Henry & Yuedall, 1979; Gur, 1978, 1979). Other studies have suggested a disturbance of functional interrelationships between the two hemi spheres in schizophrenics (Beaumont & Dimond, 1973; Carr, 1980; Green, 1978; Hatta, Yamamoto, & Kawabata, 1984; Rosenthal & Bigelow, 1972; Wexler & Heninger, 1979). Still other researchers have made a distinction between anterior and posterior functioning, and have suggested that schizophrenics show specific hypofrontal functions (Buchsbaum, DeLisi, Holcomb et ai., 1984; Ingvar & Franzen, 1974).

Cennak et at.

23

An alternative view of the schizophrenic problem suggests that schizophrenics do not show a discrete hemisphere problem, but rather manifest symptoms of bilateral brain dysfunction (Golden, 1980; Quitkin, Rifkin, & Klein, 1976). Kolb and Whishaw (1983) support the view of bilateral deficits, and they suggest the deficits are limited to bilateral dysfunction of the frontal and temporal lobes, as their schizophrenic patients performed within normal lim its on tests sensitive to parietal lobe damage. Cazzullo, Gambini, Pieri and Scarone (1984) have suggested that the right hemi~phere is primarily involved in the initial phases of schizophrenia, while left hemisphere malfunctioning is more characteristic of chronic pa tients. Some researchers have suggested that even in chronic schizophrenic patients, there is evidence of performance patterns that are consistent with right hemisphere dysfunction (Erwin, & Rosenbaum, 1979; West, 1984). Therefore, a secondary purpose of the present study was to examine whether chronic schizophrenics show symptoms of right hemisphere dysfunction, specifically right parietal lobe dysfunction. While there are many standardized assessments of perceptual motor functioning for children, there are few tests for the adult. Standardized tests of perceptual functioning for the adult that have been developed to date include components of neuropsychological assessments such as the Halstead-Reitan (Golden, Osmon, Moses, & Berg, 1981) and the Luria Nebraska (Golden, Hammeke, & Purisch, 1984). The Halstead-Reitan battery does not directly as sess constructional abilities although there are several drawings on the aphasia screening test and drawing of the blocks on the tactual performance test. Similarly, while the Luria Nebraska Neuropsy chological Battery includes some visual construction items (draw ing items in the motor category and construction of geometric pat terns from blocks in the visual category), studies which have differentiated the performance of schizophrenic patients and normal controls have not examined these particular items (Moses & Golden, 1979). In contrast, a test which emphasizes the evaluation of constructional abilities is the Parietal Lobe Test which accompa nies the Boston Diagnostic Aphasia Examination (Goodglass & Ka plan, 1972). The Parietal Lobe Test was developed to assess the sensory, visual, spatial, and cognitive capacities of the adult. Pre

24


liminary normative data on normal adults has been published (Far ver & Farver, 1982). The purposes of the present study are as follows: 1. To compare the performance of patients with chronic schizo phrenia to normal controls on a variety of tasks of construc tional abilities, and to determine if these tests differentiate be tween groups. 2. To examine the effects of age and chronicity (length of hospi talization) on the performance of the subjects with schizo phrenia. METHOD

Subjects

The subjects were 16 male chronic schizophrenic patients and 18 male normal control subjects between the ages of 30 and 60. The patient group was from the Brockton Veteran's Administration Medical Center. The diagnosis of schizophrenia was made by the attending psychiatrist based on DSM-III criteria. No schizophrenics were included for whom there was any history of neurological dis order such as cerebral trauma, epilepsy, drug abuse, or alcohol ad diction. None of the schizophrenics were drug free, being on differ ent types and amounts of neuroleptic medications. The normal controls were of comparable age and education level as the schizophrenic patients. For the most part, the normal controls were hospital employees. No normal subject was taking any neuro leptic or other medication. The mean and standard deviation of age, education level, years work, and the Shipley Institute of Living Vocabulary Scale, for each of the groups are presented in Table 1. The Shipley Institute of Living Vocabulary Scale was used as an estimate of premorbid in telligence. Analysis of variance revealed no between-group differ ence in terms of age, education level, and the Shipley Institute of Living Vocabulary Scale. As expected, there was a significant be tween-group difference in number of years employed, F(1,32) = 19.62,p < .001. The mean length of total overall time hospitalized

Cennak et al. Table 1:

SUbject Data

n

Group

Schizophrenic

16

Normal Control 18

Note:

25

Age (Yrs)

Education

Yrs Work

Shipley

X

43.94

11.44

10.57

106.94

SO

10.88

1. 86

9.05

13.37

X

43.83

12.11

26.22

113.44

SD

9.81

2.00

11. 25

9.67

Only "Years Work" is significant between groups,

E (1,32)

=

19.62, P < .001

for the schizophrenic group was 5.86 years (SD range 6 months to 14 years).

=

5.01 years;

Procedure The three constructional tests used in this study are designed to assess constructional abilities and are drawn from the Parietal Lobe Battery (Goodglass & Kaplan, 1972). These are: Drawing to Com mand and to Copy, Stick Construction, and Three Dimensional Blocks. Procedures for each of these tasks is as follows: 1. Drawing To Command and To Copy. The subject was required to draw each of the following objects to verbal command each on a separate blank sheet of paper: clock, daisy, elephant, house, red cross, and block. Models for copying each of the drawings were then provided and the subject was asked to copy each drawing. Criteria were established for the scoring of each drawing (See Table 2). Each item for each drawing was scored as a 2 (item present and with good quality), 1 (present but of fair quality), or 0 (absent or of very poor quality). Thus the range of scores for the clock drawing was from 0-10; the range of scores for the daisy was

26


Table 2:

scoring criteria for Constructional Praxis Drawings

Item 1.

Draw a clock. After it is drawn, set it at ten after eleven.

scoring criteria 1. Shape of clock (circularity) 2. Correct numbers (1 to 12) 3. spatial placement (between numbers, around edge) 4. Tim~ set (11:10) Z points = correct time & correct arm length 1 point = arms pointing to correct numbers but same length or length of arms in wrong direction) o points = wrong time 5. symmetry (right/left; up/down; four quarters)

2. Draw a daisy

1. General shape of daisy (center and petals) 2. symmetry of petals 3. Stem articulated to daisy

3. Draw an elephant

1. Relevant features (trunk, ears, tusks, eye, tail, legs) . 2. Four legs of approximately equal size 3. General shape and proportions

4. Draw a house in perspective so you can see the roof, front, and side

1. 2. 3. 4.

Roof, front, side Relevant detail (door, windcw, chimney) Perspective Correct orientation of entire house, of angles

5. Draw an out line of the red cross but don't take your pencil off the paper

1. 2. 3. 4.

Continuous inside corners continuous outside corners Basic configuration .of a red cross Symmetrical figure

6. Draw a block so we can see the top and two sides

Points lOne side 2 = Two sides 3 Three + sides 4 Three dimensional attempt 5 Three dimensional accurately produced

=

from (0-6), etc. Drawings to verbal command and to copy were each independently rated by the four authors. If three of the raters gave the drawing the same score, that was the final score. Other wise the highest and lowest ratings were dropped and the final score was the average of the two middle ratings.

Cennak et af.

27

Based on the individual scores for each drawing, total drawing scores were also determined, one for verbal command and one for copy. For the total score, drawings were prorated so that each was equally weighted for a value of 10 points per drawing (total of 60 possible points). 2. Stick Constrnction. The subject was asked to reproduce, from memory, fourteen matchstick figures. The materials for the match stick constructions consisted of twelve wooden sticks, one quarter inch square by three inches long. Each of the fourteen designs was presented one at a time, on a pre-assembled 9" x 12" paper, with the matchsticks glued on the paper. The subject was instructed to watch closely since he would be expected to make the same de signs. After the design was exposed for ten seconds, it was re moved. The subject was given the correct number of sticks and was asked to reproduce the design. After completing the designs from memory, any items in which the subject made an error were pre sented again and the subject was asked to copy the design with the matchsticks. Scoring was based on the total number of errors. When any errors were made, the therapist administering the test drew the subject's response. Each response was scored in terms of five possible error types: Orientation of entire stick construction; Gestalt - overall configuration of design; Articulation of sticks - sticks touching if they should not be, or not touching if they should be; Spatial Rela tionships of the angles in the construction; Misplacement of one or more sticks in the construction. Errors were scored as major error (1 point), minor error (112 point). Thus there was a range of 0 to 5 points per item. Stick constructions were independently rated by the four authors. As in the Drawings task, if three of the raters gave the stick construction the same error score, that was the final score. Otherwise, the highest and lowest ratings were dropped and the final error score was the average of the two middle ratings. Total error scores for the memory section and for the copy section were determined. 3. Three Dimensional Blocks. The materials consisted of photo graphs of block constructions and miniature blocks. The subject was given one photograph at a time and was asked to construct the model with his blocks. There were ten constructions made from these blocks and the subject was allowed up to one minute for each

28


construction. An accuracy score was determined based on the num ber of correct blocks in each item. Items ranged from 4 to 8 blocks per item thus there was a possible score range from 0 to 58. Each item was also timed and a total time score was calculated for each subject. RESULTS Subject Variables

For the subjects with schizophrenia, in order to examine whether subject variables including age, educational level, years work, days hospitalized or Shipley scores contributed to the prediction of scores on the constructional praxis tests, six stepwise multiple re gressions were run, one for each dependent measure: Stick mem ory, Stick copy, Block accuracy, Block time, Drawings to verbal command, Drawings to copy. On the Stick memory task, only age was significant, F (1, 14) = 5.48, P < .05, r = .53. For all other regressions, none of the subject variables significantly contributed to predicting the score on the tests of constructional abilities. Table 3 shows the correlation among the patient and task variables. Table 3:

Correlations Between Subject Variables for subjects with Schizophrenia

Age Education Yrs. Work Days Hasp. Shipley

Yrs. Work

Days Hasp.

Age

Education

1.00

-0.371

0.156

0.249

0.499

1.00

0.255

0.106

-0.010

-0.020

0.366

1.00

-0.370

1.00

Shipley

1.00

Cennak et ai.

29

Between Group Analyses

Table 4 shows the scores on each of the three major construction tasks for each group. In order to determine whether patients with schizophrenia performed differently from normal controls on con structional tasks, a series of between group ANOVAS were per formed. On the Sticks test, a 2 (Group) by 2 (Condition: Memory vs. Table 4:

Scores on Construction Tasks as a Function of Group

Group Schizophrenic

Normal Control

X

12.56

3.35

SD

8.87

2.55

X

1.20

0.26

SD

1. 34

0.62

X

52.69

56.44

SD

6.38

1.92

X

269.37

162.11

SD

155.11

72.47

X

44.79

52.57

SD

8.53

4.64

X

53.69

55.56

SD

3.90

3.06

Task

sticks-No. of errors Memory

Copy

Blocks Accuracy

Time (sec. )

Drawings Verbal Command

Copy

30


Copy) repeated measures analysis of variance was performed. Group was significant, F (1,32) = 18.98, P < .001, Condition was significant, F (1,32) = 47.97, P < .001, as was the Group by Condition interaction, F (1,32) = 15.75, P < .001. Multiple com parisons indicated that patients with schizophrenics performed sig nificantly more poorly than normal controls on the memory condi tion but there was no difference between groups in the copy· condition (see Figure 1). In order to examine between group differences on the Block Con struction task, two one way between group analyses were per formed, one for accuracy and one for time. Results indicated that schizophrenics were significantly less accurate than controls, F (1,32) = 5.68, P < .05, and took significantly longer than con trols, F (1,32) = 6.93, P < .05. For the drawing task, a 2 (Group) x 2 (Condition: Memory vs. Copy) was performed using the total pro-rated drawing score. Group was significant, F (1,32) = 9.23, P < .01, Condition was significant, F (1,32) = 40.32, P < .01, and the Group by Condi tion interaction was significant F (1,32) = 9.93, P < .01. Multiple comparisons indicated that patients with schizophrenics performed significantly more poorly than normal controls on the verbal com mand condition but there was no difference between groups in the copy condition (See Figure 2). In order to better identify whether certain drawings better differ entiated between the patients with schizophrenia and the controls for the Drawing task to verbal command, between group t-tests were performed. Significant between group differences were found for the House, t = 3.26, P < .01, for the Red Cross, t = 3.19, P < .01, and for the Clock, t = 2.05, P < .05. The Cube drawing approached significance, t = 1.93, P = .06 (See Table 5). In order to determine which of the drawings best discriminated between the groups, a stepwise logistic regression was performed using scores on the individual drawings to verbal command. Draw ings to verbal command, rather than to copy, were selected since earlier analyses indicated that individually, they better discrimi nated between the groups. The stepwise logistic regression proce dure indicated that the combined scores for house plus red cross best predicted group (p = 0.0074, R = .498, Beta = - 0.827) (See Figure 3).

15

mNormal Control [ill

rJ)

Schizophrenia

I...

a

I...

I...

10

W

15 I...

m

.0

E

:::J

Z

5

oI

lIT'""""""""""""""""",,]····:·····

r

,.",

Memory

Copy

Condition ~

Figure 1:

Number of Errors on the Sticks Test as a Function of Group and Condition

~

300

en c o o

-0

um

Normal Control

[J

Schizophrenia

200

Q)

(J)

c Q)

E

~

-

~ 100 :::s

o o

«

o

I

Figure 2:

"

Accuracy

lime

Accuracy Scores and Time Scores on the Blocks Test For Each Group

.. 33

Cennak et af.

Table 5: Orawings to Verbal Command and Copy as a Function of Group Group Item

Clock

Condition

Verbal Command Copy

Schizophrenic

X

SO X

SO Oaisy

Verbal Command Copy

X

SO X

SO Elephant

Verbal Command Copy

X

SO X

SO House

Verbal COJllmand Copy

X

SO X

SO Red Cross

Verbal Command Copy

X

SO X

SO Cube

Verbal Command Copy

X

SO X

SO

Normal Control

6.81 2.71

8.31 1. 40

8.03 1. 34

8.62 1.26

5.12 0.97

5.56 0.63

5.58 0.35

5.76 0.34

4.73 1. 22

5.26 0.64

5.55 0.74

5.83

5.86 1. 33

7.19 1. 06

7.66 0.46

7.71 0.57

5.91 1.50

7.15 0.46

6.84 0.85

7.10 0.69

3.31 1.40

4.14 1.08

4.45 0.71

4.62 0.49

0.~3

SCCAP/SC-CAPCS

The hypothesis that patients with schizophrenia would perform significantly more poorly than normal controls on a variety of con structional tasks was partially supported in that there were between group differences on most but not all tasks. Examination of the sticks and drawing tasks indicated that there was no difference be

60

~

lliI

Normal Control

[J

Schizophrenia

50

40

~ as I.

::l

U

U

30

«

20

10

0'---'-

Verbal Command

Copy

Condition Figure 3:

Accuracy on the Drawing Test as a Function of Group and Condition

Cennak et at.

35

tween groups on the task which required direct copying yet patients with schizophrenia performed significantly more poorly than con trols on performance to verbal command (drawing task) or to mem ory (stick task). These latter conditions were more complex with greater demands than the copy condition. The verbal command drawing task and the sticks memory task both require memory as well as a need for the individual to "visualize" or "conjure up the image" of what the correct response should look like. In addition, the subject doesn't have a model with which to compare his re sponse and make corrections. However, it would be inaccurate to conclude that it is the solely memory aspect that is responsible for group differences since persons with schizophrenia also performed more poorly than controls on the Block Construction task and mem ory was not demanded on this task. Rather, it appears that task complexity may be a critical variable. Persons with schizophrenia can perform simple constructional tasks as well as controls how ever, when task complexity is increased through increasing memory demands, through the need for visualization, or through dimension ality, then persons with schizophrenia no longer perform as effec tively as do controls. This may, in part, be a problem with inade quate strategies. For example, it was noted that on the memory condition of the sticks test, patients often attempted to identify and verbally code the designs. It is not clear whether this may reflect a heavier reliance on auditory vs. visual memory, an attentional de fict (Portnoff, Golden, Wood, & Gustavson, 1983), or deficits in abstract problem solving (Miller, 1984). However, the patients ver balization were often unusual and appeared to "interfere with" rather than facilitate stick reproductions. The tasks addressed in this study are typically considered mea sures of parietal function (Goodglass & Kaplan, 1972). However, we cannot conclude that because patients performed more poorly than controls, they have parietal lobe deficits. We can however state that deficits in individuals with chronic schizophrenia are not limited to language deficits, and patients do have difficulty with constructional tasks. Certain tasks appear to better differentiate between groups than others. If the results of the present study were replicated with a larger sample, then tasks from the present battery could be short

36


ened and incorporated into an occupational therapy assessment. These would include: (1) Stick construction to memory, (2) Draw ing to verbal command, with the best drawings being the house, the red cross, and the clock, and (3) Block Construction. In future studies it is critical to examine the relation of perfor mance on constructional tasks to functional performance and/or out come. Performance on constructional tasks has been viewed as es pecially important since, in certain patient groups such as the right brain damaged, it has been found to correlate highly with functional performance and with prognosis in rehabilitation outcome (e.g., Bradley, 1982; Carter et aI., 1988; Kaplan & Heir, 1982; Warren, 1981). In fact, occupational therapy treatment for individuals with perceptual deficits is predicated on a relationship between percep tual skill and functional performance. Therapists following the re-· medial, perceptual skills training approach described by Niestadt (1988) often use treatment tasks like construction of puzzles and parquetry blocks or performance of sensorimotor activities to pro vide clients with practice in deficit perceptual skills. It is assumed that improvement in perceptual skills will be accompanied by im provement in performance on functional activities such as dressing or driving a car, and several studies have supported this hypothesis (Carter et aI., 1988; Diller & Weinberg, 1977; Leer, 1984; Sivak et aI., 1981). Since the relationship between perceptual skill and func tional performance is the theoretical basis for cognitive-perceptual retraining, it is critical to define that relationship for the varied pop ulations with whom occupational therapists work. It is necessary to examine whether this relation exists in the schizophrenic popula tion, whether it is true for both chronic and/or acute disease states, and whether performance on constructional tasks alone or in combi nation with other variables, predicts functional performance. In ad dition, therapists must examine the relationship between different perceptual abilities and various functional activities. If cognitive perceptual retraining results in improvement in a patient's ability to dress himself/herself, does it also relate to improved performance in meal preparation or in driving skill, other tasks that demanding per ceptual and constructional abilities. Therapists must carefully ex amine whether it is more effective to provide cognitive-perceptual training or whether it is more effective to provide training in spe

Cermak et al.

37

cific functional activities. Comparative studies are needed to help delineate the relative utility of different treatment approaches for the individual with chronic schizophrenia. REFERENCES Anderson, E.K., & Choy, E. (1970). Parietal lobe syndromes in hemiplegia. American Journal of Occupational Therapy, 24, 13-18. Beaumont, G. & Dimond, S. J. (1973). Brain disconnection and schizophrenia. British Journal of Psychiatry, 123, 661-662. Bradley, K. P. (1982). The effectiveness of constructional praxis tests in predict ing upper extremity dressing abilities. Occupational Therapy Journal of Re search, 2, 184-185. Buchsbaum, M., Delisi, L., Holcomb, H., Cappelletti, J., King, A., Johnson, J., Hazlett, E., Dowling-Zimmerman, S., Post, R., Morihisa, J., Carpenter, W., Cohen, R. Pickar, D., Weinberger, D. Margolin, R., & Kessler, R. (1984). Anterior-posterior gradients in cerebral glucose use in schizophrenia and affective disorders. Archives of General Psychiatry, 41,. 1159-1166. Carr, S. A. (1980). Interhemispheric transfer of stereognostic information in chronic schizophrenics. British Journal of Psychiatry, 136, 53-58. Carter, L. T., Oliveira, D.O., Duponte, J., & Lynch, S. (1988). The relationship of cognitive skills performance to activities of daily living in stroke patients. American Journal of Occupational Therapy, 42, 449-455. Cazzullo, C. L., Gambini, 0., Pieri, E., & Scarone, S. (1984). Lateralized cere bral impairment in schizophrenia. Acta Psychiatry Belgium, 84, 310-324. Connolly, J. F., Gruzelier, J. H., Kleinman, K. M., & Hirsch, S. R. (1979). Lateralized abnormalities in hemisphere-specific tachistoscopic tasks in schizophrenic patients and controls. In J. H. Gruzelier & P. Flor-Henry (Eds.), Hemisphere asymmetries offunction in psychopathology, Elsevier, London. Eimon, M., Eimon, P., & Cermak, S. (1983). Performance of schizophrenic patients on a Motor-Free Visual Perception Test. American Journal of Occupa tional Therapy, 37,327-332. Endler, P. & Eimon, M. (1978). Postural and reflex integration in schizophrenic patients. American Journal of Occupational Therapy, 32, 456-459. Erwin, B., & Rosenbaum, G. (1979). Parietal lobe syndrome and Schizophrenia: Comparison of neuropsychological deficits. Journal of Abnormal Psychology, 88,234-241 Farver, P., & Farver, T. (1982). Performance of normal older adults on tests designed to measure parietal lobe functions. American Journal of Occupa tional Therapy, 36, 444-449. Flach, F. & Kaplan, M. (1983). Visual perceptual dysfunction in psychiatric pa tients. Comprehensive Psychiatry, 24, 304-31l. Flor-Henry, P. (1976). Lateralized temporal-limbic dysfunction and psychopathology. Annals of the New York Academy of Science, 280, 777-795.

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Flor-Henry, P., & Gruzelier, J. (Eds). (1983). Laterality and psychopathology. Amsterdam: North-Holland Publishing Company. Flor-Henry, P., & Yeudall, L. (1979). Neuropsychological investigation of schizophrenia and manic-depressive psychosis. In J.H. Gruzelier and P. Flor Henry (Eds). Hemispheric asymmetrics of function in psychopathology. New York: ElsevierlNorth Holland. Golden, c., Hammeke, T., & Purisch, A. (1984). Manual for the Luria-Ne braska Neuropsychological Battery. Los Angeles: Western Psychological Ser vices. Golden, C.J., Osmon, D_, Moses, J., & Berg, R. (1981). Interpretation of the Halstead-Reitan Neuropsychological Test Battery. New York: Grune & Strat ton. Goldstein, G. (1978). Cognitive and perceptual differences between schizophren ics and organics. Schizophrenia Bulletin, 4, 160-185. Goodglass, H., & Kaplan, E. (1972). Assessment of aphasia and related disor ders. Philadelphia: Lea and Febiger. Green, P. (1978). Defective interhemispheric transfer in schizophrenics. Journal ofAbnonnal Psychology, 87, 472-480. Gur, R. E. (1978). Left hemisphere dysfunction and left hemisphere over-activa tion in schizophrenia. Journal ofAbnonnal Psychology, 87, 226-238. Gur, R. E. (1979). Cognitive concomitants of hemisphere dysfunction in schizo phrenia. Archives of General Psychiatry, 36, 209-274. Halla, T., Yamamoto, M., & Kawabata, Y. (1984). Functional hemispheric dif ferences in schizophrenia: Interhemispheric transfer deficit or selective hemi sphere dysfunction? Biological Psychiatry, 19, 1027-1036. Ingvar, D. H. & Franzen, G. (1974). Abnormalities of cerebral blood flow distri bution in patients with chronic schizophrenia. Acta Psychiatry Scandinavia, 50, 425-462.

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Cennak et al.

39

between schizophrenic and parietal lesion patients with neurological tests of parietal impairment. Clinical Neuropsychology, 5, 175-178. Quitkin, F., Rifkin, A., & Klein, D. F. (1976). Neurologic soft signs in schizo phrenia and character disorders. Archives of General Psychiatry, 33, 845-853. Rosenthal, R. & Bigelow, L.B. (1972). Quantitative brain measurements in chronic schizophrenia. British Journal of Psychiatry, 121, 259-264. Schweitzer, L. (1982). Evidence of right cerebral hemisphere dysfunction in schizophrenic patients with left hemisphere overactivation. Biological Psychi atry, 17 (6), 655-678. Sivak, M., Olson, P. L., Kerman, D. G., Won, H., & Henson, D. (1981). Driv ing and perceptual/cognitive skills: Behavioral consequences of brain damage. Archives of Physical Medicine and Rehabilitation, 62, 476-483. Taylor, M.A. & Abrams, R. (1984). Cognitive impairment in schizophrenia. American Journal of Psychiatry, 141, 196-201. Taylor, M. M. (1968). Analysis of dysfunction in left hemiplegia following stroke. American Journal of Occupational Therapy, 22, 512-520. Warren, M. (1981). Relationship of constructional apraxia and body scheme dis orders to dressing performance in adult CVA. American Journal of Occupa tional Therapy, 35, 431-437. West, E. D. (1984). Right hemisphere dysfunction in schizophrenia. Lancet, 1(8372f), 344.

Wexler, B. E., & Heninger, G.R. (1979). Alterations in cerebral laterality during acute psychiatric illness. Archives of General Psychiatry, 36,278-284.

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WOMEN'S MENTAL HEALTH

IN AFRICA

Edited by ~ Esther Rothblum, PhD New Bookl Ellen Cole, PhD This landmark volume looks "This is an important and closely at the mental health of interesting book since it ad women in Africa, a topic that has dresses the problems associ been virtually unexplored until ated with women's mental health in Africa apart from those now. Replete with some of the most provocative feminist issues of men, which has not been of the day, Women's Mental done before in one volume. The Health in Africa examines the contributors cover a wide range of issues, from spirit posses economic, physical, and social factors that have a major impact slon to AIDS, in a sympathetic and scholarly manner. It should be read by all those involved in on the psychological well-being of women in African countries. medical and paramedical fields Feminist researchers unravel the and by concerned lay people." Georgina Buijs, PhD, Lecturer, Department of enormously complicated social system and the traditional Anthropology, Rhodes University, cultural values and taboos that Grahamstown, South Africa are directly related to women's For Fast Service, Call

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(a monograph published simultaneously as Women & Therapy Vol 10, No.3) $19.95 hard. ISBN: 1·56024·043·1. Available Fall 1990.

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