Fluidity Theory and Neuropsychological Impairment in Alcoholism

Transcription

1 0%% s3.g5 +.M) 1992 N&m4 Academy of Ncmqqchol~y Fluidity Theory and Neuropsychological Impairment in Alcoholism Iamie f-t. Barron and Elbert W- Russell In order to determine whether the classic alcoholic WMS pattern is the result of right hemisphere damage or the loss o fluid intelligence abilities, right-hemisphere damaged, left-hemisphere damaged, alcoholic, and control groups of 40 subjects each were matched on the variables of age and education. They were ~~ nistered the Wan-Rev~.~ed ~W~~~R) and four sensory and motor measures that were sensitive to ~atera~~~edamage but not to~~.d~~. The a~co~~~c group showed the classic pattern of a lower pe~ormance than verbal WMS IQ. Although the left hand scores on the sensory and motor tests were s~~n~~canti~ more impaired than the right hand.woresfor the right-hemisphere damaged group they were notfor the alcoholic group. These results did not support the right hen& sphere theory. Rather, as indicated by further analysis. the pattern is most adequately explained by the~u~~ theory. There are four rival explanations fm the typical pattern of performance deficit associated with alcoholism, particularly on the Wechsler Adult Intelligence Scale (WAIS). The pattern in which the Verbal Sealed Scores are relatively normal and the Performance Scaled Scores are impaired is so common, that it is considered to be a %lassic pattern (Matarazzo, 1972). This WAIS pattern in patients with chronic alcoholism, has heen well documented in the research literature (Loberg, 1977; Parsons & Fan, 1981). Parsons and Farr (1981) reviewed alcoholism studies comparing the WAIS Verbaf and Performance IQ Preparation of the data for this article was supported by the Veteran s Administration Grant No Ibe study was completed by the first author as her Professional Research Project for the Nova University PsyD program, under the supervision of the second author at the VA Medical Center, Miami, FL and rewritten for publication by the second author. Requests for reprints should be sent to Elbert W. Russell, VA Medical Center, 116B, 1201 NW 16th Street, Miami, FL

2 176 J. H. Barron and E. W. Russell (VIQ & PIQ) Scores, as well as a few tests from the Halstead-Reitan Test Battery. Beginning with Fitzhugh, Fitzhugh, and Reitan (1965), they cite 15 studies. All of the studies indicated lower PIQ than VIQ scores, with the exception of one study. There have been four major theories concerning the causation of this pattern, which are the frontal lobe damage theory, the premature-aging theory, the right hemisphere theory and the fluidity effect theory. All four theories are based on the classic pattern. In the frontal lobe hypothesis it was assumed that WAIS Performance tests were more frontal than the Verbal tests (Chelune & Parker, 1981; Gudeman, Craine, Golden, & McLaughlin 1977; Leber & Parsons, 1982; Ron, 1977; Tarter, 1975; Wedding, Horton, & Webster, 1986). The premature aging theory relies on the knowledge that in aging performance tests deteriorate faster than verbal tests. In gerontology the premature aging theory has now been incorporated into the fluidity theory (Botwinick, 1977). The frontal-lobe theory and the premature aging theory have lost credibility due to contradictory neuropathological research data (Goldstein, 1987). The third hypothesis, of right hemisphere damage, is still considered a viable hypothesis. This hypothesis is usually termed the right hemisphere damage theory. It contends that alcoholism results in significantly greater biological damage to the right hemisphere than to the left hemisphere. This theory has received considerable attention (Ellis & Oscar-Berman, 1989; Loberg, 1977; Long & McLachlen, 1974; Miller & Orr, 1980; Smith, Burt, & Chapman, 1973; Shelly & Goldstein, 1976). Previous research had found that the major effect of various forms of brain damage on the WAIS was the lateralization effect, in which verbal abilities were more impaired by left hemisphere damage and that nonverbal or performance abilities were impaired by right hemisphere damage (Reitan, 1955). Reviews and acceptance of this effect can be located in classic texts such as Lezak (1983) and Matarazzo (1972). Consequently, when alcoholics demonstrated a similar pattern on the WAIS, it was logical to generalize from the established clinical interpretation. Recently there has been a tendency to abandon the right hemisphere damage hypothesis. It has also been seriously criticized by Goldstein (1987; Goldstein & Shelly, 1980, 1981, 1982) and others (Blusewicz, Schenkenberg, Dustman, & Beck, 1977; Bolter & HaMOn, 1980). Ellis and Oscar-Berman (1989) thoroughly reviewed this entire controversy concerning the possible greater affect of alcoholic damage on the right hemisphere. While they did not find support for a right hemisphere effect, they did not offer an alternative explanation for the source of the classic alcoholic pattern. Probably the most thorough study concerning the right hemisphere hypothesis was done by Goldstein and Shelly (1982). A multivariate discriminate analysis, using several of the WAIS subtests and Halstead-Reitan subtests, was performed. The discriminate function analysis based on the lateralized cases did not classify the alcoholics into the right hemisphere group and so it did not

3 Fluidity Theory and Alcoholism 177 support the right hemisphere hypothesis. While they provided evidence against the right hemisphere lateralization theory, they did not explain the origin of the classic pattern. Also no study directly comparing the WAIS or WAIS-R pattern to lateralized measnres has been done. During the 1940s Cattell (1943) described a fluid and crystallized intelligence concept, a major theory in neuropsychology that was conceptualized in different ways by several people (Russell, 1986, pp ). The roots of the fluidity theory can be found in a 1930 paper by Babcock, who discovered that vocabulary tests were less impaired by brain damage than tests which require more actively deductive thought processing. Her discovery led to the formulation of the Shipley Institute for Living Scale (Shipley, 1940) and a number of other tests for brain damage. While Hebb (1941) apparently first clearly identified these two forms of intellectual abilities, it was Cattell (1943, 1963) and later Horn (1966, 1968) who developed the concept and demonstrated its importance. The terms fluid and crystallized intelligence are descriptive terms depicting two factors which were repeatedly obtained from factor analytic procedures applied to intellectual or cognitive abilities. They reflect different phases of the learning process. Fluid functions represent cognitive processes that involve problem solving and that utilize minimal mounts of prior learning. When the process is used repeatedly it becomes overlearned and is called crystallized. In regard to brain functioning, fluid abilities are those that require the active brain processing of novel material, while crystallized intelligence only requires the brain to retrieve well learned material. More recently, Horn (1968, 1976; Horn & Cattell, 1966, 1968, 1982) developed the work of Cattell and refined this conceptualization of intelligence. While Cattell (1943) had suggested the relationship of his theory to the effects of brain damage, Horn was instrumental, along with Hebb (1949), in emphasizing the neurological underpinnings of fluid ability. Even though the concept of fluidity, under different names, continued to be well d~umented by research (Finlayson, 1977; Fitzhugh, Fitzhugh, & Reitan, 1964; Reed & Reitan, 1963; Russell, 1974), the concept ceased to be used to any great extent in neuropsychology after the 1950s. Instead, theories related to the localization of damage dominated neuropsychology. Because lateralization findings had became so well supported in the literature by the 1907s, Matarazzo (1972) concluded that lateralization was the major effect of brain damage on the Wechsler Scales. Consequently, it is understandable that a difference between VIQ and PIQ would be attributed to lateralized hemispheric damage. During the same period when the lateralization theory was being applied to the WAIS in neuropsychology, in gerontology the fluidity theory was proposed by Botwinick (1977) to explain the effects of aging. Subsequently, Horn (1976) and Kaufman (1979) directly related the concept of fluid and crystallized intelligence to the Wechsler intelligence tests.

4 178 J. H. Barron and E. W. Russell In neuropsychology, Russell (1979, 1980) proposed that the WAIS was simultaneously effected by both laterality of brain damage and fluidity as indicated by a revised designation of hold and don t hold tests (1979). This research demonstrated that fluidity interacts with laterality on the WAIS and that the fluidity effect as produced by diffuse organic impairment appears to be almost identical to right hemisphere damage. Therefore, diffuse damage could be confused with right hemisphere effects on the WAIS. This present study has two parts which were designed to both test the right hemisphere theory and ascertain whether the alcoholic pattern of subtests on the WAIS-R is due to the fluidity effect. Method PART 1 This part of the study was designed to test the lateralization theory directly, by testing the hypothesis that while the WAIS-R shows the classic pattern with alcoholics, motor and sensory tests that utilize the same tests for each hemisphere do not indicate lateralized damage. Control patients with right and left lateralized damage were used to show that lateralized damage does effect the motor and sensory tests. Subjects. This study utilized four groups of 40 subjects who were matched on the variables of age and education. The groups were composed of subjects with: 1) diagnosed alcoholism, 2) right hemisphere damage, 3) left hemisphere damage, and 4) a normal control group. The subjects consisted of 160 right-handed Caucasian males drawn from the Veterans Administration Medical Center population. All of the subjects were patients who had been referred for a neuropsychological examination. Patients were not included if they had received a psychotic diagnosis; had depression severe enough to require hospitalization; or had a probable diagnosis of conversion reaction. The alcoholic group was comprised of inpatients who were tested after being abstinent for over 2 weeks following detoxification. All but one subject was over the age of 3.5 and all had at least a 20-year history of heavy drinking. None of the alcoholic group members were diagnosed as having other forms of neurological damage such as tumors, cerebrovascular accidents (CVAs), or a degenerative condition. The normal group was composed of patients who had a neurological examination that was negative. The lateralized brain damaged subjects were restricted to those with acute CVAs (less than 3 months old) and tumors. There were 35 CVAs and 5 tumors for the left-hemisphere damaged subjects and 27 CVAs and 13 tumors for the right hemisphere group. All of the subjects with right or left hemisphere damage were definitively diagnosed by staff

5 Fluidity Theory and Alcoholism 179 neurologists who were also connected to a medical school. The diagnosis and location of the lesions were verified using at least one of the following neurological procedures: arteriogram, computerized tomography scan (CT scan), surgery, or autopsy. There were no significant differences across the groups for either age, F(3, 156) =.013p < 998, or education, F(3,156) = p < The mean age of the total sample was (SD = 9.10) years and their mean education level was (SD = 3.07) years. Mean age and education levels are provided for all groups in Table 1. Measures. The lateralization tests (sensory and motor tests) were extracted from the Halstead-Reitan Test Battery. The exact same test was used for both hands. Consequently, one task cannot be more fluid than another. The specific lateralization measures are: The Tapping Test (TAP), the Finger Agnosia Test (FAT), the Fingertip Writing Test (FTW), and the Tactile Performance Test (TPl ). Procedure. The results of the neurological examination were entirely separate from and done prior to the neuropsychological assessment. None of the testing used in this paper was done by the authors and the examiners who did the testing were not aware of the experimental hypotheses. As previously stipulated, the major thrust of this research was focused on the comparison of the alcoholic and the right-hemisphere damaged group. The additional inclusion of the left-hemisphere damaged group and the control group was considered essential in providing adequate comparison groups. Thus it satisfied the Parsons and Farr (1981) criticism that such a specific and well controlled comparison had not been performed. Before the principle statistical analysis was performed, the normal difference between right and left hands needed to be eliminated through the use of a correction score. To determine if any correction factors were needed for any of the tests, the means of the control group for all of the sensory and motor tests were subjected to an analysis of variance (ANOVA). Only the TAP produced a mean significant difference between the right (46.72) and left (40.44) hand (6 taps), F(1, 39) = 9.85 p <.003. This six-point difference was then added to the left hand scores prior to the statistical analysis to correct for the normal difference between hands. An ANOVA was performed on the four groups for each separate sensory or motor test, followed by an individual examination of the simple main effects and the effect of the interaction caused by the lateralization of brain damage. Results The interpretation that the cognitive impairment related to alcoholism is not produced by right hemisphere damage was strongly supported by the test

6 H. Barron and E. W. Russell results (Table I). In accordance with the classic WAIS profile the PIQ on the WAIS was significantly lower than the VIQ F(1,79) = 6.12, the p = In addition to statistical significance, there was also clinical significance as the average VIQ was within the normal range of intellectual ability (VIQ = 91.62), whereas, the average PIQ score was located in the dull normal range, (PIQ = 85.02). In comparison to the alcoholic group, the right-hemisphere damaged group produced a VIQ-PIQ difference which was obviously significant (a spread of 18 points) F(l, 78) = , p <.OOl. This VIQ-PIQ split was similar to but greater than the alcoholic group difference. Although the mean of the Verbal subtests fell within the normal range (VIQ = 93.97), the mean of the Performance subtests decreased to the borderline level of functioning (PIQ = 75.97). Table 1 lists the average VIQ, PIQ, and FSIQ for all four groups, and F scores between VIQ and PIQ. In regard to the issue of lateralization related to the sensory and motor tests, the means and F ratios for the FAT, FTW, TAT, and TPT are presented as four separate two-way ANOVAs. The means, SDS, and Fs for the main effects are presented in Table 2. The ANOVA factors were obtained for the diagnostic groups (control, left hemisphere damage, right hemisphere damage, alcoholic) versus right and left hand tests. Because the control scores were so much different from the other group scores, the interaction effects were significant, above the.ool level. As all of the ANOVAs across all of the groups produced significant F ratios, a group by type analysis of the simple main effects for each test was performed to determine the locus of the difference (Table 3). More specifically, this procedure permitted the comparison of the lateralization measures between the right and left hand for both the alcoholic and right-hemisphere damaged group (Table 3). As Table 3 indicated, there was no significant difference for the alcoholics between the scores for the right and left hand on any of the four sensory or motor measures. In comparison, the right-hemisphere damaged group showed highly significant left hand impairment, on three of the tests (FAT, FTW, and TAP) and a probability that approached significance (p =.075) on the fourth test, the TPT. For the purpose of providing a comprehensive analysis, the effect of laterahzation was also examined for the left hemisphe~ group and the control group. As expected (see Table 31, left hemisphere damage produced impaired performance in the right hand, and there was no significant difference between the right and left hand of the control group. Discussion From the results of this research, it is evident that a significantly lower PIQ than VIQ does not indicate lateralized brain damage in alcoholics. The sensory and motor data provide no support for lateralized brain damage in the alco-

7 s TABLE 1 Means and SDS for Age, Education, VIQ, PIQ, and FSIQ with F Scores Between VIQ and PIQ for ail Groups of Subjects in This Study Group Mean SD Mean Age Education VIQ PIQ FSIQ SD Meall SD M&III SD MWl SD F&79) PC Control Left Right Alcoholic at Penn State University (Paterno Lib) on May 12, 2016

8 182 J. H. Barron and E. W. Russell ANOVA Group and Interaction TABLE 2 Effects for Each Sensory and Motor Test Across all Groups and Right and Left Hands Group Main Effects MWS F-Value p< Test Control Left Right Alcoholic FAT BOO Right 1.05 (1.57) 7.80 (6.92) 2.56 (2.46) 1.52 (2.31) Left 0.85 (1.70) 2.26 (2.40) 8.59 (7.25) 1.20 (1.88) FIW ooO Right 2.30 (2.25) (7.17) 4.33 (2.74) 4.50 (4.03) Left 2.32 (2.25) 4.08 (3.16) 9.32 (6.98) 4.20 (3.69) TAPa COO Right (10.09) (19.97) (8.89) (11.63) Left (7.65) (6.58) (18.32) (9.8) TFT ooo Right 7.79 (3.91) (5.24) (6.13) (5.74) Left 7.17 (3.86) (5.41) (6.37) (5.49) aa correction score has been added to the raw score for the left hand. holic group. In fact the alcoholic group was quite similar to the control group on the sensory and motor tests except for the TFT, in which the alcoholic group was bilaterally more impaired. By contrast these sensory and motor tests did show a definite lateralization effect on the right- and left-hemisphere damaged groups. The ANOVAs were significant for both the right and left hemisphere groups for all of the sensory and motor tests (with the exception of TABLE 3 Group by Type Analysis of the Right and Left Hands for Each Sensory and Motor Test for Each Group Alcoholic Right Hemisphere Damaged Test F P< Test F P< FAT FTW TAP TPT Test x66 Control F P< FAT cGil FTW BOO TAP BOO TPT Left Hemisphere Damaged Test F P FAT FAT BOO FTW.oOl.98 Ffw BOO TAP TAP BOO TFT l TPT BOO

9 Fluidity Theory and Alcoholism 183 the TPT for the right-hemisphere damaged group and that approached significance). Thus, the sensory and motor tests were sensitive to lateralized brain damage since the lateralization effect was demonstrated in the left- and righthemisphere damaged group. In view of the results of this study, it is evident that something other than the lateralized brain damage is responsible for the WAIS results which produces the classic pattern in alcoholism. PART 2 A second part of this study was preformed on this WAIS-R data to investigate whether the WAIS-R pattern for the alcoholics could be explained by the fluidity theory. A general fluidity pattern can be derived from studies by Cattell (1943, 1963) and Horn (1968, 1976; Horn & Cattell, 1966, 1968). The affect of fluid and crystallized intelligence has been described specifically on the WAIS by Botwinick (1977), Horn (1976), and Russell (1979, 1980). All three of these researchers present evidence that the Verbal subtests are measures of crystallized intelligence, while the Performance subtests are more fluid. In support of the fluidity theory, this study hypothesizes that the pattern of subtests on the WAIS-R profile of the alcoholics will be the same as that described in the studies of fluid and crystallized intelligence (Botwinick, 1977; Horn, 1976; Russell, 1979, 1980), that is the Verbal subtests will be more impaired than the Performance subtests. Procedure A mean subtest profile for the WAIS-R was obtained to investigate whether it conformed to the pattern predicted by the fluidity theory as proposed by Horn (1976) and Botwinick (1977). In their theory all of the verbal subtests were crystallized while all of the performance subtests were fluid. Thus, one would predict that the Performance tests would be more impaired than the Verbal tests if there is a fluidity effect. Using the same subjects as in the first study this fluidity pattern was examined for the alcoholics. The mean subtest scale scores the control left-hemisphere damaged, right-hemisphere damaged, and alcoholic subjects were plotted for the WAIS-R (Figure 1). The pattern of subtests for the alcoholic group was consistent with that designated as fluid and crystallized by Horn (1976) and Botwinick (1977) in that the verbal subtests were less impaired than the performance subtests. To test whether this pattern of mean scores was significant a chi square X2 statistic was applied the mean score pattern as seen in Figure 1. The WAIS-R subtest mean scores were divided at the median (7.53) for all scales. It was predicted that those above the median would be crystallized and those below the median would be fluid.

10 J. H. Barron and E. W. Russell 01 I I I I I I 1 I 1 I D V A C S PC PA BD OA DS WAIS-R SCALES FIGURE 1. WAIS-R mean subtest profiies for alcoholic, control, left-, and right-hemisphere brain damaged groups of subjects. Results The means of the alcoholic subjects for the WAIS-R are: Information 8.2, Digit Span 7.65, Vocabulary 8.0, Arithmetic 7.6, Comprehension 9.47, Similarities 7.53, Picture Completion 6.77, Picture Arrangement 5.47, Block Design 6.35, Object Assembly 4.92, and Digit Symbol The X2 dividing the subtest means at the median separated all of the verbal tests in to the less impaired or crystallized group and all of the performance subtests into the more impaired or fluid group. Since the N was less than 40 Fisher s Exact Test was used. This gave a X2(4, N = 11) with a probability level of Thus the alcoholic subjects demonstrated the pattern that was predicted for the fluidity effect. While the X2 is a simple statistical method a more complex method would, in all probability, produce the same conclusion. Discussion The above finding supports the contention that the classic alcoholic pattern on the WAIS or WAIS-R is produced by the fluidity effect and not greater right hemisphere damage. It also lends credence to the Russell (1979, 1980, 1986) contention that the existing WAIS and WAIS-R format of Verbal and

11 Fluidity Theory and Alcoholism 185 Performance tasks confounds actual hemispheric damage with the loss of fluid and crystallized ability. In fact the WAIS-R pattern for the alcoholic subjects in Figure 1 is quite similar to the WAIS pattern found for the diffuse degenerative subjects in Russell s earlier study (1979). While this sample was restricted to right-handed males, it might be beneficial to include females, and a population other than that from a Veterans Hospital. Nevertheless, these applications are not expected to change the general results that were found. The concept of fluidity has a history of being rejected by neuropsychology in the 1950s but is presently being reaccepted. It has already become one of the major organizing principles in gerontology (Botwinick, 1977). Time and again under different names the existence of this concept has been demonstrated in neuropsychology, even during the period when it was generally rejected as an explanatory concept (Cullum, Steinman & Bigler, 1983; Finlayson, 1977; Fitzhugh, Fitzhugh, & Reitan, 1964; Horn, 1968, 1976; Horn & Cattell, 1966, 1968; Kaufman, 1979; Reed & Reitan, 1963; Russell, 1974, 1979, 1980). There has apparently never been a study that has challenged the existence of a fluidity effect, since a thorough library and computer search did not locate such a study. Today it is evident that the fluidity effect is a major principle in neuropsychology that should be taken into consideration in most neuropsychological research and in all clinical interpretation (Russell, 1986). As is demonstrated by this study on the localization theory of alcoholic damage, localization research should utilize Teuber s (1955; Russell, 1986) double dissociation paradigm to ensure that differences. between tests are in fact due to localized damage and not to fluidity. When this research study carefully used Teuber s method by using bilateral motor and sensory tests along with the WAIS-R, the WAIS-R alcoholic pattern was not found to be due to a lateralization effect. On examination, all of the theories concerning the effect of alcoholism on brain functions can be explained in terms of the fluidity theory, since all of the theories are based on a greater impairment of tests that are fluid rather than crystallized. The premature-aging theory presupposes that the Performance tests will be more impaired by aging than the Verbal tests. This is the same as the fluidity pattern. Because frontal tests tend to be fluid and many posterior, especially verbal tests, are crystallized, the fluidity effect will almost always be confused with frontal damage unless this effect has been taken into account. In fact, if the fluidity theory had been acceptable in neuropsychology, the alternative theories probably would never have gained credence. These results are also important for clinical practice. In determining the focality of damage one should take the affects of fluidity into account before lthe second author would greatly appreciate being informed of any references that fail to support the existence of the fluidity theory in any of its alternate names.

12 186 J. H. Barron and E. W. Russell the focality of damage can be designated since on the WAIS-R diffuse damage often resembles right hemisphere damage. Chronic alcoholism apparently acts like a degenerative pathology as long as the person continues to drink. As such, it is important to consider the implications of alcoholism as a degenerative disease in terms of the fluidity theory. Since crystallized functions appear to be more sustained over time an individual may seem to be competent when in fact he or she is cognitively slipping. Thus, there may be the illusion of competency as long as the alcoholic, or individual with a degenerative disease, remains within the parameters of their area of expertise. The major difficulty appears in their inability to handle new problems and field changes. REFERENCES Babcock, H. (1930). An experiment in the measurement of mental deterioration. Archives of Psychology, No Blusewicz, M. J., Schenkenberg, T., Dustman, R. E., & Beck, E. C. (1977). WAIS performance in young normal, young alcoholic, and elderly normal groups: An evaluation of organicity and mental aging indices. Journal of Clinical Psychology, 33, Bolter, J. F., & Hannon, R. (1980). Cerebral damage associated with alcoholism: A reexamination. The Psychological Record, Botwinick, J. (1977). Intellectual abilities. In J. E. Birren & J. W. Schaie (Eds.), Handbook of the psyc~logy of aging (pp ). New York: Van Nostrand Re~hold. Catteli, R. B. (1943). The m~s~ment of adult intelligence. P~ch5~ogical Bulletin, 3, Cattell, R. B. (1963). Theory of fluid and crystallized intelligence. Journal of ~ducari5~a~ Psych515gy, 54, l-22. Chelune, G. J., & Parker, J. B. (1981). Neuropsychological deficits asscxciated with chronic alcohol abuse. Clinical Psychology Review, I, Cullurn, C. M., Steinman, D. R., & Bigler (1983). Relationship between fluid and crystallized cognitive functions using the Category Test and WAIS scores. The Inrernational Journal of Clinical Newopsychology, VI, (3), Ellis, R. J., & Oscar-Berman, M. (1989). Alcoholism, aging and functional cerebral asymmetries. Psychological Bulletin, 106, Finlayson, M. A. J. (1977). Test complexity and brain damage at different educational levels. Journal of Clinical Psychology, 33, Fitzhugh, K. B., Fitzhugh, L., & Reitan, R. (1964). Influence of age upon measures of problem solving and experimental back~ound in subjects with long-sending cerebral dysfunction. Journal of eeronl5logy~ 19,132-L% Fitzhugh, L., Fitzhugh, K. B., 8r Reitan, R. (1965). Adaptive abilities and intell~tu~ fu~tioning of hospitalized alcoholics: Further considerations. Quarterly Journal of Studies on Alcoholism, 26, Goldstein, G. (1987). Etiological considerations regarding the neuropsychological consequences of alcoholism. In 0. A. Parsons, N. Butters, & P E. Nathan (Eds.), Newopsychology of nlcoholism. New York: The Guilford Press. Goldstein, G. & Shelly, C. (1980). Neuropsychological investigation of brain lesion localization in alcoholics. In H. Begleiter (Ed.), Biological effects of alcohol (pp ). New York: Plenum Press. Goldstein, G., & Shelly, C. (1981). Does the right hemisphere age more rapidly than the left? Journal of Clinical Neuropsychology,

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