Reflections on Neuropsychology

Thus, the Fool may indicate the whole range of mental phases between mere excitement and madness, but the particular phase in each divination must be judged by considering the general trend of the cards, and in this naturally the intuitive faculty plays an important part.
~ Arthur E. Waite, occultist and co-creator of the Rider-Waite Tarot

I recently got the following message via email. It has been some time since I have thought in great detail on what happened to me, last year. And while I answered the letter, it caused me to reflect on my own experiences. The letter was short and to the point:

A friend of mine who has suffered from severe depression and who has had ECT is facing neuropsych testing to assess his work fitness and is rather anxious. Can you lead me to online sample test questions I can share with him (he’s not online)?

The tests I underwent were a modified version of the Halstead-Reitan test battery designed by the rehabilitation hospital to which I was admitted. The hospital specializes in brain trauma. I wrote some of my thoughts about the tests. In those entries I have given a couple of vague examples. I came to realize I have not truly described what these tests were like.

I do not mean to suggest by describing these tests that there is some way to be prepared for them. That is one of the elements I found the most frustrating about these tests: I could not study for them—by design. Unlike so many other tests, these tests did not seem to focus on what I had—or had not—learned. Rather they looked at whether I was capable of learning and to what degree. To that end they measure psychological functions known to be linked to particular brain structures or pathways. Before the injury I may have argued that this sort of testing was merely an updated version of phrenology. I do not argue that now.

Do not misunderstand. I still tend to consider psychology a form of augury. It is that with some time and perspective that I begin to see a method. And occasionally I see some results. Not always. Not about everything. But some of these experiences have proven occasionally helpful.

The tests are based on what I consider a somewhat unsteady presupposition. A neuropsychologist compares my raw score on a test to a comparable sample of other people. Before the tests even begin, there is an extensive interview to determine my age, level of education, background and ethnicity. These variables then come into play when trying to interpret my results. My raw score is compared to a group of people just like me—minus the brain injury. I suppose the ideal would be to have a baseline evaluation before the injury and then after. That scenario has some unfortunate impracticality associated with it. So we are left with the unsteady presupposition that a group of similar people can accurately represent me in my pre-morbid state. Such are the challenge of divination, I suppose.

What follows are some descriptions of some of the tests I took as well as my color commentary. There were other tests: facial recognition memory tests, verbal comprehension and memory, non-verbal comprehension and memory, geometric puzzle solving. What follows are the standout tests. The tests I remember the most about—mostly due to the anxiety and anger they generated in me when taking them. However time and recovery have given me some distance on these tests and an opportunity to reflect on them with a bit more circumspection.

California Verbal Learning Test
The California Verbal Learning Test assesses an individual’s verbal memory. Many of the tests I underwent had both a verbal and a non-verbal component to them. Here my torturer read aloud a list. The list contains sixteen common words. Each word belonged to one of four categories—not that they told me that part. Four fruits, four herbs and spices, four vegetables, four meats. Then they asked me to recall as many of these items as possible—as quickly as possible. Rinse. Repeat.

I was assessed on how many items I could remember over several repetitions. I was also assessed on whether I used the category information. No, I cannot remember the specific items (or their categories) now, but lets say for sake of discussion that one category was fruit and the four fruits were: apples, bananas, oranges and cherries. If I remembered all four, that would be ideal. If I remember only apples, cherries and bananas, but guess that the fourth item was probably grapes—another fruit—I demonstrated that I understood the major category at least.

Nest step, a second list. Similar categories. Same scenario. The bonus question: I was expected to keep the items from the first list separate from the items in the second list.

And then, just when I thought I had had about enough fun, they added another twist. We go on to do some other tests, and about twenty minutes later come back and do these two again. “Tell me what was on the first list, again?”

Trail Making Test
The trail-making test was fairly simple. I drew a route connecting twenty-five numbers randomly arranged on a piece of paper. Simple connect-the-dots sort of things here. One, two, three, four. Of course the clock is ticking while I do this. The clock is ticking on almost all of these tests. And I at least inferred that ‘faster is better’. But without any sort of context, I just ended up rushing. Maybe that is the point.

Now for the second part. In the second part of the test, I had to draw a line that connected alternating letters and numbers. So: 1, A, 2, B, 3, C, 4, D, 5, E, et cetera.

The time it takes to draw the line gives an estimate for cognitive and psychomotor response speeds. The second section does all that, too, but further complicates things by requiring me to deal with more than one piece of information, aspect of a task, or train of thought simultaneously.

Stroop Tasks
In psychology, the Stroop effect is a demonstration of interference in the reaction time of a task. When a word such as blue, green or red is printed in a color differing from the color expressed by the word’s semantic meaning a delay occurs in processing the word’s color. This leads to slower reaction times and increased mistakes.

Go ahead: try it. Say the words in the gray box to the right as fast as you can. There are two sets. You should find the first set easier to do correctly—and faster—than the second set. This is the Reading Color Names task.

The second version of this test is the Naming Colored Words task. Instead of reading the words despite their colored typeface, verbally identify the color of each printed word. That is, say the color of the typeface, not the semantic meaning of the printed word.

But wait! There’s more. In a third version, some words had boxes around them. For words in boxes I was asked to name the color of the words—Naming Colored Words. For words without a box I was asked to read the word—Reading Color Names. This, as you probably guessed, puts further strain on the executive function of the brain. Mind you, these were long strings of words. They filled almost an entire page. Some were mis-colored: red text on the word blue. Some matched color and word. Some had boxes around them. Some had boxes around them that were mis-colored. More fun than walking naked into a room full of strangers.

Brown-Peterson Consonant Trigrams
The Brown-Peterson Constant Trigrams test memory under interference. It is allegedly very useful in determining subtle neuropsychological deficits in people with head injuries.

I look at a collection of consonants—the trigram. An example might be MVC, GRK, or JCW. Then I got to do algebra. I actually was pretty good at algebra. For me it was counting backwards by threes, starting at thirty. So: 30, 27, 24, 21, 18, 15, et cetera. The algebra serves as the interference.

Apparently the trend is that the longer a person spends working on the interference the harder it is to remember the trigram. I did not know it at the time I was taking the test, but the amount of time they had me doing the algebra was a key factor in the test. Sometimes it would be three seconds. Sometimes it would be nine seconds. Sometimes it would be eighteen. And here I thought that they just wanted to see if I would mess up the algebra portion.

Wisconsin Card Sorting Task
The Wisconsin Card Shifting Task tested my ability to display flexibility in the face of changing schedules of reinforcement.

Initially, I was presented with four cards: the first has one red triangle, the second has two green stars, the third has three yellow crosses, and the fourth has four blue circles. I was then given a stack of additional cards and asked to match each one to one of the four stimulus cards, thereby forming four separate piles of cards. The psychologist did not tell how to match the cards; however, he did tell me whether a particular match was right or wrong.

Trial and error. Pick a method of matching: shape, color, number. Apply the method. See what happens. After a certain number of correct matches, the rules change. Of course no one tells you that the rules have changed. So here I am happily sorting by color when all of a sudden my method fails. Try again. Fails again. Try again—obstinately expecting different results. No dice.

So you have to recognize that the rules have changed, and start sorting by new rules. Of course you have to find the new rule, first. This goes on for quite some time. When I got my results of my neuropsychological test battery, I asked about this one. They told me there is a criteria for how long the test lasts. The task continues for 128 cards or until nine rule changes have been accomplished successfully. And the rules change after it has been successfully applied to five cards. So the minimum would be 45 cards. Give a couple extra cards for discovering errors—after all the test is designed so that you cannot be certain of your method unless you test failed possibilities.

Paced Auditory Serial Addition Test
This test is pure sadism. It is the test I remember most clearly. It is the test that caused me the most emotional aggravation. I hate this test. I despise this test. This test should find a home in and among the circles of Dante’s Hell to be acted out over and over again on misguided psychologists for the rest of their lives.

The test is comprised of a pre-recorded tape which delivers a random series of sixty-one numbers from one through nine. I was required to add pairs of numbers such that each number is added to the one—and only the one—immediately preceding it. Thus if the first four numbers were 6, 3, 5, 8, the answers would be 9, 8, and 13, respectively. It sounds simple, but it is not. Go ahead. Try it. I’ll wait.

Fun, ain’t it?

We have not gotten to the fun part. Here is the fun part: although the same string of numbers is presented on four separate trials, these trials are done at differing rates of presentation. They start at a nice, easy pace of one number every two and a half seconds. Then they speed up. In the fourth trial the numbers are presented at a rate that is twice as fast as the first trial. This increases processing demands by increasing the speed of stimulus input.

I was able to handle the first two trials fairly well. I would miss a number here or there, or lose track of what was being said on the tape. But I recovered quickly enough. I would wait for a couple numbers to come by take it up again. By the third trial I was growing frustrated. The fourth trial was an exercise in futility—and rage.

It was this task that caused me to file away a question for my mild-mannered tormentor. I guessed that I would get an opportunity to ask questions about what I had just undergone. And I guessed correctly. At the end of everything, he asked me just that. I had one question. One burning question that I wanted answered:

Have you had this done to you—have you sat in my chair and taken all of these tests?

His answer was one of the most reassuring I had had to date. He had taken all of these tests. It was a requirement to giving the test to anyone. He had walked the same miles as I had.

Of course, his brain was still intact.