Anosodiaphoria for dressing apraxia: contributory factor to dressing apraxia

ELSEVIER

Clinical Neurology and Neurosurgery 96 (1994) 25-I 250

Case report

Anosodiaphoria

for dressing apraxia: contributory dressing apraxia

factor to

Yoshihiro Takayamaay Morihiro Sugishita”>*, Syuichi Hirose’, Ichiro Akiguchi’ “Department qf‘ Cognitive Neuroscitwr,

Research hstitutr qf Logopedics and Phoniatrics. L’niver.rityof Tok>~j. 7-2-I IfWI~“. Wtnk,w-ku. Tokyo 113, Jqmn hDrpartment of Neurology, Facuit_vs~fMedicine, Kyoto Universit1: 54 Kuwahara-cho. S~V,~~III.Sakyo-ku. K.yoto 6Of1.Jupm

Revived 19 April 1994; accepted 6 June 1994 _-Abstract

We report 2 patients with bilateral dressing apraxia. One patient had prominent bilateral dressing apraxia without severe constructional apraxia together with anosodiaphoria for dressing apraxia. The other patient had mild dressing apraxia with severe constructional apraxia and was aware of her disabilities. This dissociation implies that anosodiaphoria for dressing apraxia is an important factor in the severity of bilateral dressing apraxia. This also explains why automatic acts in dressing are more severely affected than when patients are asked to put clothing on in dressing examination. Key fjords: Dressing apraxia; Anosodiaphor~~ Constru~t~onaI apraxia -__~__ _~___

1. Introduction Brain [l] reported 2 patients with brain damage who were unable to dress themselves properly. IIe defined this disturbance of dressing in daily life as dressing apraxia. Benson and Geschwind [2] postulated that bilateral dressing apraxia is secondary to constructional apraxia. However, the severity of constructional apraxia sometimes does not correlate with the severity of dressing apraxia. In this report, we present two patients with bilateral dressing apraxia and discuss this issue from the view point of anosodiaphoria. Anosdiaphoria is used to describe a patient who is aware of a neurological impairment but appears unconcerned about it [3].

2. Ciinical material Patienr 1

A 78-year-old right-handed woman experienced transient left hemiparesis. Since then, she had difficulty dress*Corresponding author. Tel.: (+81-3) 5802 3328; Fax: (+81-3) 5802 3329. ~303-8447/94/$7.00 Q 1994

Elsevier Science B.V. All rights reserved SSDl ~303-8467(94)0003 I -Z

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ing herself. Computed tomography demonstrated a right parietal infarction. Four months later, when admitted to our hospital, she was alert and cooperative. Left hemianopsia was demonstrated by Goldmann perimetry. Her eye movements were normal. There was no paresis. Mild left hemisensory disturbance was revealed. There was no cerebellar or visuomotor ataxia. Her total 1Q was 83. with a verbal 1Q of 95 and a performance IQ of 64. Her score on Raven’s colored progressive matrices was 26/36 for a grade of II. which was above normal. There was no indication of aphasia. Unilateral spatial neglect (USN) was not demonstrated in a line bisection task and canccllation task, though on a copying task she showed mild signs of left USN. Finger agnosia and right-left disorientation were absent. She was able to gesture or imitate gestures upon command. She was also able to perform sequential object manipulation smoothly. She did not show ideomotor apraxia or ideational apraxia. Her raw score on Kohs Block test was 10. She copied drawings fairly well (Fig. 1A) and exhibited only mild constructional apraxia. Dressing. When a piece of clothing was laid on the table, she could identify parts of the clothing. She could

answer all of the following questions correctly: ‘What is ‘Is this?‘; answer: ‘neck,’ ‘sleeve, ’ ‘cuff or ‘buttonhole’. this the front or back?’ ‘Is this the right or left?’ ‘Is this up or down?’ ‘Where is the neck, sleeve, cuff or buttonhole?’ Nevertheless, it was difficult for her to put on clothing in a semiautomatic fashion. She often manipulated the clothes incoherently, turning and reversing them and handling them haphazardly in her daily dressing routine. Her dressing disturbance could be demonstrated by turning one sleeve of her pajamas inside out and then asking her to put them on. She tried to put her arm into one sleeve while the pajamas were held upside down. She turned the pajamas inside out and turned them around, upside down. She mistook the front for the rear as well as right for left. She attempted to pull the sleeve hole over her head. Sometimes, it was difficult to align the buttons with the correct buttonholes. Essentially, she showed similar difficulty when putting on a sweater, blouse, undershirt, slacks or skirt. When asked, she admitted that she had difficulty in dressing, although she was not seriously concerned about her dressing disturbances. She was able to dress by herself, if she laid the clothes out first on a table. Her dressing ability improved when she was told to put her clothes on slowly, thus making her aware of her disturbance. However, it was difficult to adopt dressing strategies by herself in daily life. When clothing was handed to her, she usually began dressing promptly as though she had no di~culty in dressing. Patient

2

A 24-year-old right-handed woman suffered from shock during surgery of the hand. MR images demonstrated bilateral parieto-occipital ischemic lesions. When we evaluated her 4 years later she was alert and cooperative. There was a left lower quadrantanopia visualized by Goldmann perimetry. Her eye movements were normal. There was no paresis, sensory disturbances, nor cerebellar ataxia. Her verbal IQ was 98 with a performance IQ under 60. Her score on Raven’s colored progres-

model

&f-l Fig. I. Drawings

by patient

1 (A) and patient 2 (B).

sive matrices was 4136. There was no indication of aphasia. Mild left unilateral spatial neglect was demonstrated by the line bisection task and cancellation task. Finger agnosia was absent. She was able to gesture or imitate gestures upon command. She was able to perform sequential object manipulation smoothly. She did not exhibit ideomotor apraxia or ideational apraxia nor could she perform the simplest task on the Kohs Block test. Also, she could not copy simple drawings (Fig. 1B). She had severe constructional apraxia. She dressed slowly and was aware of her Dwssing. dressing disabilities. She carefully checked her clothes before trying to put them on and seldom made errors in her daily dressing routine. When she did make errors, they were not restricted to one side. She could identify parts of her clothing. In summary, patient 1 showed prominent bilateral dressing apraxia without severe constructional apraxia, while patient 2 showed minimum bilateral dressing apraxia with severe constructional apraxia.

3. Discussion It is widely accepted that there are two primary neuropsychological symptoms that can secondarily cause dressing apraxia 12.41. These are constructional apraxia and unilateral spatial neglect. Unilateral dressing apraxia is secondary to unilateral spatial neglect. Patients carefully dress and groom half of the body, the side ipsilateral to the cerebral lesion, while completely ignoring the other side. Bilateral dressing apraxia is secondary to constructional apraxia. Such patients show total disarray, whereby clothes are put on in the wrong order or from the wrong end. They are unable to manipulate an article of clothing in space. Our patients showed bilateral dressing apraxia. If bilateral dressing apraxia is indeed secondary to constructional apraxia, the severity of dressing apraxia would be expected to correlate with the severity of constructional apraxia. However, this is not the case. In some patients, bilateral dressing abilities are impaired in relatively isolated fashion without severe constructional apraxia, like patient 1 in our study and patient 3 in Hecaen and de Ajuriaguerra [5]. Patients with severe constructional apraxia sometimes do not show prominent dressing apraxia like patient 2 in our study, patient I in Helnphill and Klein [6J and patients 1 and 4 in McFie et al. [7] . Patient 1 admitted that she had a dressing disability when asked, but appeared unconcerned about it. thus indicating an anosodiaphoria for dressing apraxia. Patent 2 was deeply concerned about her dressing disability. In dressing, clothes that belong to outside space have to bc iilc(~rp~~~~ted in one‘s body shape. Appropriate move-

ments have to be carried out to transfer clothing from one orientation to the other. As dressing is such a complex act, mild constructional apraxia should cause prominent dressing apraxia in those patients who simultaneously had anosodiaphoria for dressing apraxia. Such patients minimize their disabilities and can not compensate for them. This explains why automatic acts in dressing are more severely affected than dressing upon request under test conditions, as stated in the literature, which is not the case in other apraxias. Factors that might contribute to dressing ability have been investigated. Williams [S] and Warren [9] reported that there was a significant relation between dressing and written copying tasks. Walker and Lincoln [lo] reported that dressing ability was most closely associated with performance on tasks designed to measure visual inattention, such as a cancellation task. However, dressing apraxia has seldom been viewed from the point of anosodiaphoria. It might be quite important when disabilities in daily life, such as dressing apraxia, are taken into account .

References [l]

Brain,

R. (1941)

Visual disorlrnratlon

[2] Benson, D.F. disturbances. Neurology, [3] Critchley,

in: Baker, Harper

A.B.

and Baker.

and Row. New York.

E. Krieger

M.L.

;md rcl;~red

I. 11. (Eds.1. Clinical NI’.

(‘hap.

II).

Lobeb. Hal‘ner, Nca

(lY86)

Human

Yyrk.

\I’

Neuropsycholop).

Publishing Co.. Malabar.

[S] H&caen, H. and de Ajuriaguerra. chic paralysis

11‘

Brain.

M. (1966) The Parietal

[4] H&.zaen, H. and Albert, Robert

with q’ec~al rctcrcncs

I : 34-l _772. and Geschwind.I\;.(1906)The aphasia

lesions of the right hemisphere.

J. (1954) Balint’s syndrome (ps)-

of Gsual fixation)

and its minor forms. Brain.

77.

373400. [6] Hemphill, disability J. Ment. [7] McFie,

R.E. and Klein. R.

f IY48)

Contribution

to the dressing

as a focal sign and to the imperception

phenomena.

Sci., 94: 61 1~612. J., Piercy, M.F.

and Zangwill.

OL.

( 1950)Lisual-spat~itl

agnosia associated with lesions of the right cerebral

hemisphere.

Brain, 73: 167-190. [S] Williams,

N. (1967) Correlation

ing activities in hemiplegia. [9] Warren, body

M.

(1981)

Relationship

scheme disorders

Am. J. Occup. Ther., [IO] Walker,

M.F.

699 701.

of constructional

to dressing performance

1332 1340. apraxia

in adult

and (‘VA.

35: 431 -43?.

and Lincoln,

ing performance

between copymg abihty and dress-

Am. J. Phys. Med., 46:

N.B. (1991) Factors influencing dress-

after stroke. J. Neural.

Neurosurg.

Psychiat.. S4: