RAVEN'S COLORED PROGRESSIVE MATRICES AND INTELLECTUAL IMPAIRMENT IN PATIENTS WITH FOCAL BRAIN DAMAGE

Transcription

1 RAVEN'S COLORED PROGRESSIVE MATRICES AND INTELLECTUAL IMPAIRMENT IN PATIENTS WITH FOCAL BRAIN DAMAGE Claudio Villardita (Neuropsychology Unit, Department of Neurology, University of Catania) INTRODUCTION The evaluation of intellectual impairment due to focal brain damage and the question of whether there are areas of the cortex critical to general intelligence (factor "g" as defined by Spearman, 1923) raise thorny problems. A unilateral focal lesion may give rise to two kinds of neuropsychological deficit (De Renzi and Faglioni, 1965); either an impairment of specific cognitive abilities (verbal, visuo-spatial and praxic) related to the anatomical site of the damage or a global mental deterioration, mainly affecting abstract thought (Goldstein, 1948). The latter is conceived by some authors (Lashley, 1929; Hebb, 1942; Goldstein, 1948) as dependent on the size and not on the site of the damage, while others (De Renzi and Faglioni, 1965; Basso, De Renzi, Faglioni, Scotti and Spinnler, 1973) believe that damage to specific areas of the cortex is critical. Attempts to identify these crucial areas, through the study of brain-damaged patients, have always been hampered by awkward problems of method. It has been pointed out (De Renzi and Faglioni, 1965, Basso et ai., 1973; Basso, Capitani, Luzzatti and Spinnler, 1981) that the impairment of a single cognitive ability may obstruct the assessment of mental deterioration in brain-damaged patients. Significant in this regard are the low scores of aphasics on verbal intelligence tasks: it is, in fact, highly probable that the deficit in such cases is related to aphasia than to mental deterioration. These problems of method led Basso et al. (1973) to suggest that the ideal test for assessing intellectual impairment in brain damaged patients should involve no verbalization, subtle differentation of visuospatial data or complex manipulative skills. A test at least partially fulfilling these requirements is Raven's Progressive Matrices (RPM) either in the standard form (RSPM - Raven, 1958) or in the colored version (RCPM - Raven, 1962), which is shorter and simpler. Despite its reliability and homogeneity the test often yielded equivocal results. While it is generally accepted that brain focal damage Cortex (1985) 21,

2 628 Claudio Villardita depresses the scores, it is still not clear in which of the two hemispheres damage produces the more severe deficit. According to some authors (Costa and Vaughan, 1962; De Renzi and Faglioni, 1965; Colonna and Faglioni, 1966; Archibald, Wepman and Jones, 1967a; Basso et ai., 1973, Denes, Semenza and Stoppa, 1978) there is no significant difference on RCPM performance between right and left brain-damaged patients. Others (Arrigoni and De Renzi, 1964; Kertesz and McCabe, 1975) report poorer performance by left brain-damaged patients. According to yet other studies (Archibald, Wepman and Jones, 1967b; Costa, Vaughan, Horwitz, and Ritter, 1969; Costa, 1976) right brain-damaged patients perform worse, though the difference disappears when adverse influence of neglect is excluded (Gainotti, Caltagirone and Miceli, 1977). There is a similar uncertainty about the influence of aphasia, thought by some authors to playa detrimental role on the performance (Colonna and Faglioni, 1966; Basso et ai., 1981), which was discounted by others (Arrigoni and De Renzi, 1964; De Renzi and Faglioni, 1965; Zangwill, 1964; Boller and Vignolo, 1966; Archibald et ai., 1967b; Kertesz and McCabe, 1975). A possible explanation of this discordance came from Costa (1976) who pointed out that three sets (A, Ab, B) of which RCPM is made up have no homogeneous laterality index, in that set A would mainly tap visuospatial ability, set Ab gestalt-like processing and set B analogical and abstract thinking. On these grounds Costa expected right brain-damaged patients to perform worse on set A and left brain-damaged patients on set B, a prediction only partially born out by his data, though some support for it can be found in the work of Denes et al. (1978), and of Zaidel, Zaidel and Sperry (1981). The homogeneity of the items categorized under the same set is, however, questionable (Bromley, 1953; Burke, 1958; Rinoldi and Nieto, 1962) and we suspect that not all the items of set A mainly hinge on visuospatial abilities and not all the items of set B are analogical problems. In this study we grouped the items of RCPM according to whether the detection of the correct response involved the principle of sameness, symmetry or analogy (Bromley, 1953), on the assumption that problems involving sameness depend upon perceptual abilities, those involving symmetry imply internal verbalization for the analysis of stimulus features, and those involving analogy depend upon conceptual thinking. Based on these assumptions, we expected right brain-damaged patients to fare worse on the items of the first type and left brain-damaged patients in those of the second and third type. We sought also to find out whether aphasia exerts a differential influence on the different part of the test.

3 Progressive Matrices and brain damage MATERIALS AND METHOD Subjects The study was conducted on 20 normal controls and 48 right-handed stroke patients, 24 with right (RBD) and 24 with left (LBD) hemisphere damage. The side of lesion was diagnosed on the basis of neurological examination, CT scan and clinical course. Patients with bilateral damage, patients in coma for more than 72 h after onset of symptoms, patients with a history of previous stroke and patients presenting CT signs of severe cerebral atrophy were excluded. The Token test score (De Renzi and Faglioni, 1978) were used to divide the 24 LBD cases into two groups, 10 patients without aphasia (LDB Aph-) and 14 patients with aphasia (LBD Aph + ). The control group was made up of 20 patients admitted to the Neurological Department of Catania University for peripheral nervous system disorders and who were free from clinical and CT evidence of brain focal lesions. The four groups were comparable in age (RBD: mean 61.16, sd 8.73; LBD Aph-: mean 60.79, sd 7.91; LBD Aph+: mean 62.34, sd 6.81; Controls: mean 62.15, sd 8.53) and schooling (from 5 to 10 years). Severity of brain damage, based on the size of CT lesions (Luzzati, Scotti and Gattoni, 1979) and the degree of sensory-motor and visual field defects (Bisiach, Cappa and Vallar, 1983) did not differ significantly across the hemispheric groups. Brain-damaged patients were tested 30 to 40 days after the stroke. Test Procedure RCPM (Raven, 1962) was administered in the standard sequence of items proposed by Raven but the response array for each item was arranged vertically, as proposed by Caltagirone, Gainotti and Miceli (1977), to reduce the influence that neglect for left-sided alternatives may have on the performance of right brain-damaged patients. No time-limit was set. The four groups were compared with respect to total score (maximum: 36) and with respect to the score achieved in each of the following three sets: Set I It included the 11 items (AI; A 2 ; A 3 ; A4; As; A 6 ; Ab l ; Ab 2 ; Ab 3 ; BI; B 2 ) which call for the identification of sameness to arrive at the correct solution. Problems of this type are simplest intellectually (Raven, 1965) and have been claimed to be contingent on visuo-perceptual ability (Costa, 1976). The maximum score is 11. Set II It included the 19 item (A7; As; A 9 ; A IO ; All; A\2; Ab4; Ab 5; Ab 6 ; Ab7; Abg ; Ab 9 ; Ab lo ; Abll : B 3 ; B4; Bs; B 6 ; B7) the solving of which calls for the use of the principle of symmetry. Space-perceptual analysis is no longer the unique prerequisite and the analysis of the features characterizing the stimulus and the alternatives (lenght and direction of lines, arrangement of dots, wideness, of angles, and so on, Zaidel and Sperry, 1973) is likely to be aided by covert verbalization. Tha maximum score in this set is

4 630 Claudio Villardita Set III It included the 6 most complex problems (Ab 12 ; Bg; B 9 ; B\O; B JI ; B 12 ) of the test (Bromley, 1953; Raven, 1965). Their correct solution depends on the discovery of reciprocal analogical relationship between the three parts making up stimulus set, thus making these 6 problems most appropriate for unraveling disturbances of general intelligence (Bromley, 1953; Raven, 1965; Costa, 1976; Zaidel et al., 1981). They are in fact the last to be solved by the developing intelligence and the first to fox the declining intelligence (Raven, 1965). The maximum score for this set is 6. Statistical Procedures The total scores of the groups were first submitted to variance analysis (Completely Randomized Design, Bruning and Kintz, 1977) and then to Scheffe's test for multiple comparisons. Set I, II and III scores were compared by means of a nonparametric procedure because nonhomogeneous variances were observed in some cases. For this purpose we used Van der Waerden Normal Scores Test for Independent Samples (Conover, 1980). The same test was used for the multiple comparisons. RESULTS Table I gives the means and standard deviations of the RCPM total scores and set scores for the four groups. ANOV A of the total scores shows highly significant differences across the four groups (F = 25.31; d.f. = 3, 64; P <.001) and multiple comparisons (Table II) reveal that each of the three brain-damaged groups perform more poorly than controls, although they do not significantly differ between them. Also on set I brain-damaged patients score poorer than controls, but there is, in addition, an impairment of RBD patients in comparison to LBD patients without aphasia (Table III). TABLE I Means and Standard Deviations of Raven's Scores in the Four Groups Total Scores Set I Scores Set II Scores Set III Scores Mean S.D. Mean S.D. Mean S.D. Mean S.D. Controls l l RBD Patients l l.58 l.67 LBD Aph - Patients l LBD Aph + Patients

5 Progressive Matrices and brain damage 631 TABLE II Inter-Group Comparisons of Total Scores (Scheffe's test) Controls VS. RBD Patients Controls VS. LBD Aph - Patients Controls VS. LBD Aph + Patients RBD Patients VS. LBD Aph - Patients RBD Patients VS. LBD Aph + Patients LBD Aph - Patients VS. LBD Aph + Patients *p =.05 Difference between Critical p the means value * 4.36* 4.36* <.001 <.001 <.001 n.s. n.s. n.s. In set II (Table IV), on the other hand, the decisive factor in disrupting the performance in represented by aphasia. LBD patients with aphasia fare significantly worse than the other two brain-damaged groups. TABLE III Inter-Group Comparisons of Set I Scores (Van der Waerden Normal Scores Test for Several Independent Samples) T. = dj. = 3 p <.001 Multiple Critical Comparisons (Ai-A) value p Controls VS. RBD Patients <.001 Controls VS. LBD Aph - Patients <.01 Controls VS. LBD Aph + Patients <.001 RBD Patients VS. LBD Aph - Patients <.01 RBD Patients VS. LBD Aph + Patients n.s. LBD Aph - Patients VS. LBD Aph + Patients n.s. TABLE IV Inter-Group Comparisons of Set II Scores (Van der Waerden Normal Scores Test for Several Independent Samples) T. = dj. = 3 p <.001 Multiple Critical Comparisons (Ai-Aj) value p Controls VS. RBD Patients <.001 Controls VS. LBD Aph - Patients <.001 Controls VS. LBD Aph + Patients <.001 RBD Patients VS. LBD Aph - Patients n.s. RBD Patients VS. LBD Aph + Patients <.001 LBD Aph - Patients VS. LBD Aph + Patients <.002

6 632 Claudio Villardita TABLE V Inter-Group Comparisons of Set III Scores (Van der Waerden Normal Scores Test for Several Independent Samples) TI = d.f. = 3 p <.001 Multiple Critical Comparisons (Ai-Aj) value p Controls VS. RBD Patients n.s. Controls VS. LBD Aph - Patients <.05 Controls vs. LBD Aph + Patients <.01 RBD Patients vs. LBD Aph - Patients <.05 RBD Patients vs. LBD Aph + Patients <.02 LBD Aph - Patients vs. LBD Aph + Patients n.s. Table V compares the performance on set III. It shows that LBD patients, with or without aphasia, perform significantly worse than the other groups, RBD patients as well as controls, which in tum, are not significantly different from each other. DISCUSSION On total score the brain-damaged groups did significantly worse than controls, but differed little from each other. We failed to confirm the greater deficit of RBD patients, reported in some previous studies (Costa et al., 1969; Costa 1976), probably because we reduced the influence of neglect by adopting the vertical presentation of alternatives suggested by Caltagirone et al. (1977). As to aphasia, its presence is associated with the poorest mean, but the difference with respect to the other brain-damaged groups is not significant, contrary to what reported by Basso et al. (1973), who found aphasics significantly deteriorated in comparison to nonaphasic left brain-damaged patients. It must be emphasized, however, that size of the samples studied in the two researches is different; there were 55 aphasic and 41 non- aphasics in Basso et al.'s study, while they are 14 and 10, respectively, in ours.lt is, therefore, quite possible that increasing the number of patients would confirm the significant impairment of aphasics. A different pattern of impairment emerges from the analysis of the single set data. On set I, which is cognitevely elementary but involves visuoperceptual factors, it was the RBD group which scored lower, followed by aphasic LBD patients, thus suggesting that RBD patients' poor performance reflects a deficit of perceptual organization rather than an intellectual impairment in the strict sense. Basso et al. (1973) reached an

7 Progressive Matrices and brain damage 633 analogous conclusion, based on the high correlation found in RBD patients, between the Raven test and the Mixed Figure test scores. Zaidel and Sperry (1973) likewise noted that in commissurotomy patients the right hemisphere uses a gestalt-like spatial apprehension strategy for solving the Matrices whife the left hemisphere relies on sequential verbal reasoning processes. The importance of internal verbalization processes for a correct choice emerges clearly in set II items which are more liable than those of set I to verbal coding; here the presence of aphasia is critical in determining a deterioration of the performance. Set III, whose items require problem-solving skills, reasoning by analogy and conceptual thinking, is sensitive to left hemisphere injury, independently of aphasia, but insensitive to right hemisphere damage. The absence of difference between aphasic and nonaphasic LBD patients, must, however, be evaluated with caution, since it may be due to a "floor effect" present in the performance of both groups. At any rate, it would appear that the more the task becomes demanding at the level of "intelligent behaviour" the more the role of the left hemisphere is critical. Evidence for this was provided by Basso et al. (1973) who showed that LBD patients low scores on Raven Progressive Matrices were associated with a deficit in abstract thinking evidenced by their performances on the Weigl sorting test. Also Zaidel et al. (1981), studying commissurotomy patients by means of two versions of the Raven test (RSPM and RCPM) pointed out a definite dominance of the left hemisphere in solving the most complex problems and in activating an appropriate error correction strategy. As to the finding that RDB performance on set III is indistinguishable from that of controls, it may be hypothesized that, when confronted with visuospatial difficulties, RBD patients are able to take advantage from their relatively intact intellectual abilities to make up for their specific perceptual impaiment (Teuber, Battersby and Bender, 1951; Arrigoni and De Renzi, 1964; De Renzi and Faglioni, 1965; Costa et al., 1969). ABSTRACf To assess the validity of Raven's Colored Progressive Matrices (RCPM) as a measure of intellectual impairment after focal brain damage, we compared the performance of 24 right brain-damaged patients, 24 left brain-damaged patients (10 non-aphasic and 15 aphasic) and 20 controls on the RCPM. In addition to the total, we analyzed the scores obtained on each of the three sets in which the 36 items of the test could be categorized on the grounds of the cognitive ability mainly involved for their solution. The first set, which calls for the identification of sameness, posed special problems to RBD patients. The second set, which involves the principle of symmetry, was selectively failed by aphasic patients. The third set, which is more demanding in terms of analogical

8 634 Claudio Villardita and conceptual thinking, was poorly performed by left brain-damaged patients, aphasics as well as non-aphasics. The implications of these findings for the relation of focalized brain damage to intelligence is discussed. REFERENCES ARCHIBALD, Y.M., WEPMAN, LM., and JONES, L.V. Performance on nonverbal cognitive tests following unilateral cortical injury to the right and left hemisphere. Journal of Nervous and Mental Disease, 145: 25-36, 1967 (a). ARCHIBALD, Y.M., WEPMAN, J.M., and JONES, L.V. Nonverbal cognitive performance in aphasic and nonaphasic brain-damaged patients Cortex, 3: , 1967 (b). ARRIGONI, G., and DE RENZI, E. Constructional apraxia and hemispheric locus of lesion. Cortex, 1: , BASSO A., DE RENZI, E., FAGLIONI, P., SCOTIl, G., and SPINNLER, H. Neuropsychological evidence for the existence of cerebral areas critical to the performance of intelligence tasks. Brain, 96: , BASSO, A., CAPITANI, E., LUZZA TIl, C, and SPINNLER, H. Intelligence and left hemisphere disease. The role of aphasia, apraxia and size of lesion. Brain, 104: , BISIACH, E., CAPPA, S., and VALLAR, G. Guida al/'esame Neuropsicologico. Milano: Raffaello Cortina Editore, 1983, pp BOLLER, F., and VIGNOLO, L.A. Latent sensory aphasia in hemisphere damaged patients: An experimental study with the Token Test. Brain, 89: , BROMLEY, D.B. Primitive forms of response to the matrices test. The Journal of Mental Science, 99: , BRUNING, J.L., and KINTZ, B.L. Computational Handbook of Statistics, 2nd ed. Glenview: Scott, Foresman 1977, pp BURKE, H.R. Raven's Progressive Matrices: a review and critical evalutation, The Journal of Genetic Psychology, 93, , CALTAGIRONE, C., GAINOTIl, G., and MICELI, G. A new version of Raven's Colored Matrices designed for patients with focal hemispherical lesions. Minerva Psichiatrica, 18: 9-16, COLONNA, A., and FAGLIONI, P. The performance of hemisphere-damaged patients on spatial intelligence tests. Cortex, 2: , CONOVER, W.J. Practical Nonparametric Statistics. New York: John Wiley & Sons, 1980, pp COSTA, L.D. Interset variability on the Raven Colored Progressive Matrices as an indicator of specific ability deficit in brain-lesioned patients. Cortex, 12: 31-40, COSTA, L.D., and VAUGHAN, H.G. Performance of patients with lateralized cerebral lesions: Verbal and perceptual tests. Journal of Nervous and Mental Disease, 134: , COSTA, L.D., VAUGHAN, H.G., HORWITZ, M., and RITTER, W. Patterns of behavioral deficit associated with visual spatial neglect. Cortex, 5: , DENES, F., SEMENZA, C., and STOPPA E. Selective improvement by unilateral braindamaged patients on Raven Colored Progressive Matrices. Neuropsychologia, 16: , DE RENZI, E., and F AGLIONI, P. The comparative efficiency of intelligence and vigilance tests in detecting hemispheric cetebral damage. Cortex, 1: , DE RENZI, E., and FAGLIONI, P. Normative data and screening power of a shortened version of the Token Test. Cortex, 14: 41-49, GAINOTII, G., CALTAGIRONE, C., and MICELI, G. Poor performance of right braindamaged patients on Raven Colored Progressive Matrices: derangement of general intelligence or of specific abilities. Neuropsychologia, 15: , GOLDSTEIN, K. Language and Language Disturbances. New York: Grune.and Stratton, 19~.. HEBB, D.O. The effect of early and late brain injury on test scores and the nature of normal adult intelligence. Proceedings of the American Philosophical Society, 85: , 1942.

9 Progressive Matrices and brain damage 635 KERTESZ, A, and MCCABE, P. Intelligence and aphasia: Performance of aphasics on Raven's Colored Progressive Matrices (RCPM). Brain and Language, 2: , LASHLEY, K. Brain Mechanisms and Intelligence. Chicago: University of Chicago Press, LUZZATTI, C, SCOTTI, G., and GATTONI, A Further suggestions for cerebral CT-localization Cortex, 15: , RAVEN, J.C. Standard Progressive Matrices: Sets A, B, C, D and E. London: Lewis, 1958 (originally published in 1938). RAVEN, J.C Colored Progressive Matrices Sets A, A", B. London: Lewis, 1962 (originally published in 1947). RAVEN, J.C Guide to Using the Colored Progressive Matrices Sets A, A", B. London: Lewis, RINOLDI, H.J., and NIETO, G.M. Informe preliminar sobre standardizacion de los tests de Matrices Progresives de Raven. Revista de Psicologia General y Applicada, 1: 55-74, SPEARMAN, C.E. The Nature of Intelligence and the Principles of Cognition. London: Macmillan, TEUBER, H.L., BATTERSBY, W.S., and BENDER, M.B. Performance of complex visual tasks after cerebral lesions. Journal of Nervous and Mental Disease, 114: , ZAIDEL, D., and SPERRY, R.W. Performance on the Raven's Colored Progressive Matrices test by subjects with cerebral commisurotomy. Cortex, 9, 34-39, ZAIDEL, E., ZAIDEL, D., and SPERRY, R.W. Left and right intelligence: case studies of Raven's Progressive Matrices following brain bisection and hemidecortication. Cortex, 17: , ZANGWILL, O.L. Intelligence in aphasia. In AV.S. de Reuck and M. O'Connor (Eds.), Disorders of Language. London: Churchill, 1964, pp Claudio Villardita, Istituto di Clinica Neurologica dell'universita, Policlinico, Viale A. Doria 6, Catania (Italy).

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