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Attempted clinical application of a technique for promoting robust free recall to a case of alcoholic Korsakoff's syndrome
BRAIN
AND
COGNITION
9, 151-157 (1989)
Attempted Clinical Application of a Technique for Promoting Robust Free Recall to a Case of Alcoholic Korsakoff’s Syndrome R. WALTER
HEINRICHS
Queen Street Mental Health Centre, Toronto, Ontario,
Canada
A case study is reported which attempted to teach personal orienting information (i.e., recent history) to an amnesic male patient. The structured cuing methods reported by Kovner, Mattis, and Pass (1985, Journal ofclinical and Experimental Neuropsychology, 7, 395-411) were adopted. This involves structured presentation and cuing of target words embedded in a narrative. Some patients eventually are able to freely recall large amounts of material presented in this way. In the present case, the patient received 30 training sessions over 8 weeks. The material to be remembered was 10 target words pertaining to recent personal history. These words were embedded in accompanying storyline. The patient’s immediate recall at the end of each session improved to some extent over the training period. However, delayed recall for the material remained nil throughout. Twelve months after the last training session the patient showed some “implicit” retention of the material. The findings are contrasted with Kovner et al.‘s dramatic results and discussed. G> 19x9 Academic PKSS. IK.
In an intriguing series of recent studies, Kovner, Mattis, and their associates (1983, 1984, 1985) have provided evidence that under certain conditions, some amnesic patients can learn and freely recall large quantities of previously presented information. Data have been presented for five patients with anterograde amnesias due to varying etiologies including alcoholic Korsakoff’s syndrome, severe head trauma, hypoxia, and medialtemporal lobe hemorrhage. These investigators employ a technique which involves the structured presentation and cuing of words embedded in a narrative. This narrative may or may not involve striking imagery (see Kovner, Mattis, & Pass, This article is based on a poster presented at the 15th annual convention of the International Neuropsychological Society, Washington, DC, February 19-21, 1987.Address correspondence and reprint requests to Dr. R. Walter Heinrichs, Department of Psychology, York University, 4700 Keele Street, North York, Ontario, Canada M3J IP3. I51 0278-2626189$3.00 CopyrighL 0 1989 by Academx Press. Inc. All rights of reproduction in any form reserved.
152
R. WALTER HEINRICHS
1985). While numerous training sessions are required, patients nonetheless engage successfully in free recall of this material, with retention intervals of up to 7 weeks between stimulus exposure and recall. Such findings are inconsistent with many current views of chronic organic amnesia. It is generally accepted that limited types of learning can occur (Cohen, 1984; Glisky, Schacter, & Tulving, 1986). However, these types of learning typically do not require the amnesic to consciously retrieve a previous event following significant delay. Indeed, rapid forgetting is, almost by definition, impaired in amnesia (see Butters & Miliotis, 1985). While Kovner et al. (1985) did not suggest clinical applications for their success in promoting recall, their work has clinical implications. A common feature of Korsakoff patients is their disorientation and confusion with respect to recent and ongoing personal history and environment. Reducing this disorientation and confusion would be an important contribution to the psychological care and management of memory-impaired patients. The case study reported here was carried out with a number of purposes in mind. First, the feasibility of developing a clinical intervention for loss of personal history in amnesia was of interest. A second goal was to attempt a partial replication of Kovner et al’s (1985) surprising results. This goal was augmented by the availability of a patient for study who represented a relatively “pure” memory disorder, with little evidence of concurrent frontal lobe cognitive deficits. The structure of the training sessions closely approximated the method reported by the original investigators. However, there were some differences. In the present study training sessions were more frequent, usually three to four per week instead of one per week. The resultant retention intervals were correspondingly reduced. In addition, personally relevant information rather than unusual or arbitrary narrative was used. METHOD Subject. The patient studied was a 49-year-old male with a history of chronic alcoholism who had been diagnosed as having Korsakoff’s syndrome. Clinically the patient appeared thin, disoriented, and unable to explain why he was in hospital or what events had led up to hospitalization. Neuropsychological test data (see Table I) showed intellectual ability within average range (WARS-R). There was no evidence of significant frontal lobe dysfunction on the basis of the patient’s Wisconsin Card Sorting Test performance. Another test sensitive to frontal impairment, oral word fluency, was also within average limits. In terms of memory tests, he obtained an MQ of 63, which was 28 points below his full scale IQ. Such large discrepancies provide one index of impaired memory (see Squire & Shimamura, 1986). The patient was unable to learn any of the “hard” paired associates on the Wechsler Memory Scale. Delayed recall after 30 min was nil for paragraphs and visual designs. Given 10 practice trials involving a simple story, he showed no learning and no recall after 30 min. Digit span was average. The patient also “released” normally
153
ROBUST FREE RECALL TABLE NEUROPSYCHOLOGICAL
1 TEST RESULTS
Test
Scores
WAIS-R FSIQ
VIQ PIQ
91 92 92
Wisconsin Card Sorting Test Categories Perserverative Errors Percent Perseverative Errors
5 10 8
Oral Word Fluency (Total) Wechsler Memory Scale
32
MQ
63 3.5 0 0 I 0 0 10 0
Immediate Semantic Memory Delayed Logical Memory (Total) Percent Retained Immediate Visual Reproduction Delayed Visual Reproduction Percent Retained Paired Associates “easy” “hard” Release from PI Trials (9-word lists) I II III IV V Semantic Shift
on the semantic shift trial of a proactive inhibition test. This administration included a warning of the impending semantic change (see Winocur, Kinsbourne, & Moscovitch, 1981). On the basis of these data and the clinical observations of continuous memory impairment over several years, it is reasonable to conclude that the patient suffered from severe anterograde amnesia. Stimuli. The stimulus material consisted of a single IO-word list selected from the normative information published by Paivio, Yuille, and Madigan (1969). The words were comparable on such properties as imagery, concreteness, and frequency of usage. They were presented in the form of a narrative account which linked them together into a “chunked” but meaningful story of recent history. The story began as follows, with list words in italics and chunked units indicated by semicolons: “I have been at Queen Street Mental Health Centre for over a year; for many years I abused alcohol; as a result I became ill and went to hospital in London; my bruin was affected, causing poor memory; the doctors transferred me to Toronto; here I can be closer to the homes of my family; now I go to Industrial therapy with my friend; I am
154
R. WALTER HEINRICHS TABLE 2 NUMBER OF WORDS RECALLED OVER SESSIONS
Session
Beginning End
Beginning End
Beginning End
Beginning End
1
2
3
4
5
6
7
8
9
0
0 2
0 2
0 1
0 2
0 1
0 2
0 3
0 3
10
11
12
13
14
15
16
17
18
0 2
0 3
0 3
0 5
0 3
0 4
0 4
0 3
0 5
19
20
21
22
23
24
2s
26
27
0 3
0 4
0 4
0 4
0 4
0 4
0 5
0 3
0 4
28
29
30
0 3
0 4
0 3
trying to remember to keep my clothing clean; I also need to keep my body clean; I can find my room by walking down the hall to room 39.” Procedure. In the initial session the full story was read to the patient with instructions to remember the emphasized target words. An immediate free recall trial followed, with the patient being asked to retell the story including target words. On the next three trials the narrative was not reread. Instead, the patient was asked to recount the story, and cuing was initiated as necessary in order to elicit the target item. This followed the method described by Kovner et al. (1985) for the first 13 weeks of their study. Thus “context” cues consisted of surrounding text (e.g., ‘&as a result I became ill and went to in London”). ‘Category” cues involved the semantic class of the target (e.g., a building for sick people). Item cues involved providing the target directly (hospital). Then on the fifth and final trial free recall without cuing was requested. The patient received 30 training sessions over 8 weeks, which averaged to 1 session every 1.8 days. At the beginning of the second session, and for each subsequent session to number 30, the patient was asked first to freely recall the target words and story presented during the previous session. The training then proceeded as indicated above. The two dependent variables were the number of words recalled at the end of each session (l-30) and the number recalled at the beginning of each session (2-30). In addition, the patient was administered a written copy of the paragraph with the target words replaced by blanks. This was done 12 months following the last training session. The patient was asked to fill in each blank, with no mention being made of any previous exposure to this material.
RESULTS AND DISCUSSION
Table 2 indicates the number of words recalled from the lo-word list at the beginning and end of each session. Over the 30 sessions only the end of session recall increased, changing from 0 at session one to 3 units by the eighth session. Performance then leveled off at about 4 words
ROBUST
FREE RECALL
155
recalled for the remaining sessions. Recall at the beginning of each session was nil throughout. On a fill-in-the-blanks measure administered a year after training the patient entered 9 of the 10 target words correctly. His only error was in substituting “mind” for “brain” as the fourth target word. It was observed clinically that the patient benefited from the retrieval cues during each training session. He increasingly became facile at recalling the target words and narrative with less and less of the need for being told the actual words. However, some minimal need for cuing was always present. Moreover, the patient never evinced any recall of the training sessions themselves. At the beginning of each session he would declare complete ignorance that any previous sessions had occurred. Less formal evaluation also showed that by the end of training, the patient could supply answers to certain specific questions. For example, he could supply an answer to a question such as: “What do you do most days?” which was related closely to the stimulus material. Similarly, when questioned, he was able to indicate how his room could be found. Clinical ward staff reported that he appeared more alert and less bewildered. Nonetheless, it is difficult to determine whether the patient used the stimulus material spontaneously to orient himself in the environment. He remained disoriented to time and showed little initiative or motivation. In future work an independent measure of confusion and orientation may prove helpful in assessingthe behavior of amnesics outside of the structured learning session. The case study raises some questions with respect to reports of successful recall in amnesic patients. Kovner et al. reported successful free recall of 20-word lists in two patients after only 6-10 sessions. What could account for such relative success and the present failure? One possibility is that methodological alterations removed the learning effect. However, it would be difficult to maintain that the ways in which the present study differed from other efforts was sufficient to account for failure. Requiring a patient to learn less information, which is more meaningful, over shorter, retention intervals, would not appear to be a likely cause of failure to learn (see also Knight & Wooles, 1980, for relevant review). Another possibility rests in the nature of the stimulus material which was employed. Perhaps the personal content involved a negative valence which interfered with learning. This is difficult to rule out given the lack of experimental controls and the use of only one type of stimulus material. A more likely argument to explain this study’s failure to demonstrate successful delayed free recall would be that previous reports may have used subjects who were less severely amnesic. For example, Kovner et al. (1985) reported MQs of 100 and 83 in their patients, compared with an MQ of 63 in the present case. It is not clear how their patients
156
R. WALTER HEINRICHS
performed on tests of delayed recall. It appears that their patients could remember that training sessions had occurred a week before. In the present case there was no realization that such sessions had occurred. Perhaps relatively mild memory impairments may be more amenable to the methods reported by Kovner and associates. It follows that use of the term “amnesic” may have to be more rigorously demonstrated as some recent authors (i.e., Squire & Shimamura, 1986) suggest. Two other points require clarification: the improvement in immediate recall, and the ability to successfully retrieve target words a year later within the context of a fill-in-the-blanks type of measure. Improvement in immediate memory may reflect the specificity of the training technique (see Gianutsos, 1981). It may also reflect an improvement in attention and arousal which is brought about by the task demands for active processing. With respect to the patient’s success in correctly filling in blanks with target words, the present methodology does not allow for specifying how this apparent learning took place. The patient may have been continuously storing personal information which was then elicited by the contextual cues of the surrounding text. However, the words used were so specific to the training stimuli that some type of information storage may indeed have occurred during training. This effect requires more thorough investigation and may be accommodated best in relation to current views of “implicit” learning in amnesia (Schacter & Graf, 1986)and the literature on repetition-priming in amnesia (see Cohen, 1984). In conclusion, the efficacy of structured cuing techniques could not be demonstrated objectively in this case of severe anterograde amnesia. The findings are in general agreement with prevailing views of organic amnesia rather than with the findings reported by Kovner et al. Precise specification of the severity of amnesia would facilitate other replication and intervention efforts. REFERENCES Butters, N., & Miliotis, P. 1985. Amnesic disorders. In K. Heilman & E. Valenstein (Eds.), Clinical neuropsychology. New York: Oxford Press. 2nd ed. Cohen, N. J. 1984. Preserved learning capacity in amnesia: Evidence for multiple memory systems. In Larry R. Squire & Nelson Butters (Eds.), Neuropsychology of memory. New York: Guilford Press. Gianutsos, R. 1981. Training the short- and long-term verbal recall of a post-encephalitic amnesic. Journal of Clinical Neuropsychology, 3, 143-153. Glisky, E., Schacter, D., & Tulving, E. 1986. Learning and retention of computer-related vocabulary in memory-impaired patients: Method of vanishing cues. Journal of Clinical and Experimental Neuropsychology, 8, 292-312. Knight, R. G., & Wooles, I. M. 1980. Experimental investigation of chronic organic amnesia: A review. Psychological Bulletin, 88, 753-771. Kovner, R., Mattis, S., & Goldmeier, E. 1983. A technique for promoting robust free recall in chronic organic amnesia. Journal of Clinical Neuropsychology, 5, 65-71.
ROBUST FREE RECALL
157
Kovner, R., Mattis, S., & Pass, R. 1985. Some amnesic patients can freely recall large amounts of information in new contexts. Journal of Clinical and Experimental Neuropsychology,
7, 39.5-411.
Lezak, M. D. 1983. Neuropsychological assessment. New York: Oxford Press. 2nd ed. Mattis, S., & Kovner, R. 1984. Amnesia is as amnesia does: Toward another definition of the anterograde amnesias. In Larry R. Squire & Nelson Butters (Eds.), Nelrropsychology of memory. New York: Guilford Press. Paivio, A.. Yuille, J. C., & Madigan, S. 1968. Concreteness, imagery, and meaningfulness values for 925 nouns. Journal of Experimental Psychology Monograph, 76, (1, Pt. 2). Schacter, D., & Graf, P. 1986. Preserved learning in amnesic patients: Perspectives from research on direct priming. Journal of Clinical and Experimental Neuropsychology, 8, 727-143. Squire, L. R., & Shimamura, A. 1986. Characterizing amnesic patients for neurobehavioral study. Behaviorul Neuroscience, 100, 866-877. Winocur, G., Kinsbourne, M., & Moscovitch, M. 1981. The effect of cueing on release from proactive interference in Korsakoff amnesic patients. Journal of Experimental Psychology:
Human Learning
and Memory,
7, 56-65.
AND
COGNITION
9, 151-157 (1989)
Attempted Clinical Application of a Technique for Promoting Robust Free Recall to a Case of Alcoholic Korsakoff’s Syndrome R. WALTER
HEINRICHS
Queen Street Mental Health Centre, Toronto, Ontario,
Canada
A case study is reported which attempted to teach personal orienting information (i.e., recent history) to an amnesic male patient. The structured cuing methods reported by Kovner, Mattis, and Pass (1985, Journal ofclinical and Experimental Neuropsychology, 7, 395-411) were adopted. This involves structured presentation and cuing of target words embedded in a narrative. Some patients eventually are able to freely recall large amounts of material presented in this way. In the present case, the patient received 30 training sessions over 8 weeks. The material to be remembered was 10 target words pertaining to recent personal history. These words were embedded in accompanying storyline. The patient’s immediate recall at the end of each session improved to some extent over the training period. However, delayed recall for the material remained nil throughout. Twelve months after the last training session the patient showed some “implicit” retention of the material. The findings are contrasted with Kovner et al.‘s dramatic results and discussed. G> 19x9 Academic PKSS. IK.
In an intriguing series of recent studies, Kovner, Mattis, and their associates (1983, 1984, 1985) have provided evidence that under certain conditions, some amnesic patients can learn and freely recall large quantities of previously presented information. Data have been presented for five patients with anterograde amnesias due to varying etiologies including alcoholic Korsakoff’s syndrome, severe head trauma, hypoxia, and medialtemporal lobe hemorrhage. These investigators employ a technique which involves the structured presentation and cuing of words embedded in a narrative. This narrative may or may not involve striking imagery (see Kovner, Mattis, & Pass, This article is based on a poster presented at the 15th annual convention of the International Neuropsychological Society, Washington, DC, February 19-21, 1987.Address correspondence and reprint requests to Dr. R. Walter Heinrichs, Department of Psychology, York University, 4700 Keele Street, North York, Ontario, Canada M3J IP3. I51 0278-2626189$3.00 CopyrighL 0 1989 by Academx Press. Inc. All rights of reproduction in any form reserved.
152
R. WALTER HEINRICHS
1985). While numerous training sessions are required, patients nonetheless engage successfully in free recall of this material, with retention intervals of up to 7 weeks between stimulus exposure and recall. Such findings are inconsistent with many current views of chronic organic amnesia. It is generally accepted that limited types of learning can occur (Cohen, 1984; Glisky, Schacter, & Tulving, 1986). However, these types of learning typically do not require the amnesic to consciously retrieve a previous event following significant delay. Indeed, rapid forgetting is, almost by definition, impaired in amnesia (see Butters & Miliotis, 1985). While Kovner et al. (1985) did not suggest clinical applications for their success in promoting recall, their work has clinical implications. A common feature of Korsakoff patients is their disorientation and confusion with respect to recent and ongoing personal history and environment. Reducing this disorientation and confusion would be an important contribution to the psychological care and management of memory-impaired patients. The case study reported here was carried out with a number of purposes in mind. First, the feasibility of developing a clinical intervention for loss of personal history in amnesia was of interest. A second goal was to attempt a partial replication of Kovner et al’s (1985) surprising results. This goal was augmented by the availability of a patient for study who represented a relatively “pure” memory disorder, with little evidence of concurrent frontal lobe cognitive deficits. The structure of the training sessions closely approximated the method reported by the original investigators. However, there were some differences. In the present study training sessions were more frequent, usually three to four per week instead of one per week. The resultant retention intervals were correspondingly reduced. In addition, personally relevant information rather than unusual or arbitrary narrative was used. METHOD Subject. The patient studied was a 49-year-old male with a history of chronic alcoholism who had been diagnosed as having Korsakoff’s syndrome. Clinically the patient appeared thin, disoriented, and unable to explain why he was in hospital or what events had led up to hospitalization. Neuropsychological test data (see Table I) showed intellectual ability within average range (WARS-R). There was no evidence of significant frontal lobe dysfunction on the basis of the patient’s Wisconsin Card Sorting Test performance. Another test sensitive to frontal impairment, oral word fluency, was also within average limits. In terms of memory tests, he obtained an MQ of 63, which was 28 points below his full scale IQ. Such large discrepancies provide one index of impaired memory (see Squire & Shimamura, 1986). The patient was unable to learn any of the “hard” paired associates on the Wechsler Memory Scale. Delayed recall after 30 min was nil for paragraphs and visual designs. Given 10 practice trials involving a simple story, he showed no learning and no recall after 30 min. Digit span was average. The patient also “released” normally
153
ROBUST FREE RECALL TABLE NEUROPSYCHOLOGICAL
1 TEST RESULTS
Test
Scores
WAIS-R FSIQ
VIQ PIQ
91 92 92
Wisconsin Card Sorting Test Categories Perserverative Errors Percent Perseverative Errors
5 10 8
Oral Word Fluency (Total) Wechsler Memory Scale
32
MQ
63 3.5 0 0 I 0 0 10 0
Immediate Semantic Memory Delayed Logical Memory (Total) Percent Retained Immediate Visual Reproduction Delayed Visual Reproduction Percent Retained Paired Associates “easy” “hard” Release from PI Trials (9-word lists) I II III IV V Semantic Shift
on the semantic shift trial of a proactive inhibition test. This administration included a warning of the impending semantic change (see Winocur, Kinsbourne, & Moscovitch, 1981). On the basis of these data and the clinical observations of continuous memory impairment over several years, it is reasonable to conclude that the patient suffered from severe anterograde amnesia. Stimuli. The stimulus material consisted of a single IO-word list selected from the normative information published by Paivio, Yuille, and Madigan (1969). The words were comparable on such properties as imagery, concreteness, and frequency of usage. They were presented in the form of a narrative account which linked them together into a “chunked” but meaningful story of recent history. The story began as follows, with list words in italics and chunked units indicated by semicolons: “I have been at Queen Street Mental Health Centre for over a year; for many years I abused alcohol; as a result I became ill and went to hospital in London; my bruin was affected, causing poor memory; the doctors transferred me to Toronto; here I can be closer to the homes of my family; now I go to Industrial therapy with my friend; I am
154
R. WALTER HEINRICHS TABLE 2 NUMBER OF WORDS RECALLED OVER SESSIONS
Session
Beginning End
Beginning End
Beginning End
Beginning End
1
2
3
4
5
6
7
8
9
0
0 2
0 2
0 1
0 2
0 1
0 2
0 3
0 3
10
11
12
13
14
15
16
17
18
0 2
0 3
0 3
0 5
0 3
0 4
0 4
0 3
0 5
19
20
21
22
23
24
2s
26
27
0 3
0 4
0 4
0 4
0 4
0 4
0 5
0 3
0 4
28
29
30
0 3
0 4
0 3
trying to remember to keep my clothing clean; I also need to keep my body clean; I can find my room by walking down the hall to room 39.” Procedure. In the initial session the full story was read to the patient with instructions to remember the emphasized target words. An immediate free recall trial followed, with the patient being asked to retell the story including target words. On the next three trials the narrative was not reread. Instead, the patient was asked to recount the story, and cuing was initiated as necessary in order to elicit the target item. This followed the method described by Kovner et al. (1985) for the first 13 weeks of their study. Thus “context” cues consisted of surrounding text (e.g., ‘&as a result I became ill and went to in London”). ‘Category” cues involved the semantic class of the target (e.g., a building for sick people). Item cues involved providing the target directly (hospital). Then on the fifth and final trial free recall without cuing was requested. The patient received 30 training sessions over 8 weeks, which averaged to 1 session every 1.8 days. At the beginning of the second session, and for each subsequent session to number 30, the patient was asked first to freely recall the target words and story presented during the previous session. The training then proceeded as indicated above. The two dependent variables were the number of words recalled at the end of each session (l-30) and the number recalled at the beginning of each session (2-30). In addition, the patient was administered a written copy of the paragraph with the target words replaced by blanks. This was done 12 months following the last training session. The patient was asked to fill in each blank, with no mention being made of any previous exposure to this material.
RESULTS AND DISCUSSION
Table 2 indicates the number of words recalled from the lo-word list at the beginning and end of each session. Over the 30 sessions only the end of session recall increased, changing from 0 at session one to 3 units by the eighth session. Performance then leveled off at about 4 words
ROBUST
FREE RECALL
155
recalled for the remaining sessions. Recall at the beginning of each session was nil throughout. On a fill-in-the-blanks measure administered a year after training the patient entered 9 of the 10 target words correctly. His only error was in substituting “mind” for “brain” as the fourth target word. It was observed clinically that the patient benefited from the retrieval cues during each training session. He increasingly became facile at recalling the target words and narrative with less and less of the need for being told the actual words. However, some minimal need for cuing was always present. Moreover, the patient never evinced any recall of the training sessions themselves. At the beginning of each session he would declare complete ignorance that any previous sessions had occurred. Less formal evaluation also showed that by the end of training, the patient could supply answers to certain specific questions. For example, he could supply an answer to a question such as: “What do you do most days?” which was related closely to the stimulus material. Similarly, when questioned, he was able to indicate how his room could be found. Clinical ward staff reported that he appeared more alert and less bewildered. Nonetheless, it is difficult to determine whether the patient used the stimulus material spontaneously to orient himself in the environment. He remained disoriented to time and showed little initiative or motivation. In future work an independent measure of confusion and orientation may prove helpful in assessingthe behavior of amnesics outside of the structured learning session. The case study raises some questions with respect to reports of successful recall in amnesic patients. Kovner et al. reported successful free recall of 20-word lists in two patients after only 6-10 sessions. What could account for such relative success and the present failure? One possibility is that methodological alterations removed the learning effect. However, it would be difficult to maintain that the ways in which the present study differed from other efforts was sufficient to account for failure. Requiring a patient to learn less information, which is more meaningful, over shorter, retention intervals, would not appear to be a likely cause of failure to learn (see also Knight & Wooles, 1980, for relevant review). Another possibility rests in the nature of the stimulus material which was employed. Perhaps the personal content involved a negative valence which interfered with learning. This is difficult to rule out given the lack of experimental controls and the use of only one type of stimulus material. A more likely argument to explain this study’s failure to demonstrate successful delayed free recall would be that previous reports may have used subjects who were less severely amnesic. For example, Kovner et al. (1985) reported MQs of 100 and 83 in their patients, compared with an MQ of 63 in the present case. It is not clear how their patients
156
R. WALTER HEINRICHS
performed on tests of delayed recall. It appears that their patients could remember that training sessions had occurred a week before. In the present case there was no realization that such sessions had occurred. Perhaps relatively mild memory impairments may be more amenable to the methods reported by Kovner and associates. It follows that use of the term “amnesic” may have to be more rigorously demonstrated as some recent authors (i.e., Squire & Shimamura, 1986) suggest. Two other points require clarification: the improvement in immediate recall, and the ability to successfully retrieve target words a year later within the context of a fill-in-the-blanks type of measure. Improvement in immediate memory may reflect the specificity of the training technique (see Gianutsos, 1981). It may also reflect an improvement in attention and arousal which is brought about by the task demands for active processing. With respect to the patient’s success in correctly filling in blanks with target words, the present methodology does not allow for specifying how this apparent learning took place. The patient may have been continuously storing personal information which was then elicited by the contextual cues of the surrounding text. However, the words used were so specific to the training stimuli that some type of information storage may indeed have occurred during training. This effect requires more thorough investigation and may be accommodated best in relation to current views of “implicit” learning in amnesia (Schacter & Graf, 1986)and the literature on repetition-priming in amnesia (see Cohen, 1984). In conclusion, the efficacy of structured cuing techniques could not be demonstrated objectively in this case of severe anterograde amnesia. The findings are in general agreement with prevailing views of organic amnesia rather than with the findings reported by Kovner et al. Precise specification of the severity of amnesia would facilitate other replication and intervention efforts. REFERENCES Butters, N., & Miliotis, P. 1985. Amnesic disorders. In K. Heilman & E. Valenstein (Eds.), Clinical neuropsychology. New York: Oxford Press. 2nd ed. Cohen, N. J. 1984. Preserved learning capacity in amnesia: Evidence for multiple memory systems. In Larry R. Squire & Nelson Butters (Eds.), Neuropsychology of memory. New York: Guilford Press. Gianutsos, R. 1981. Training the short- and long-term verbal recall of a post-encephalitic amnesic. Journal of Clinical Neuropsychology, 3, 143-153. Glisky, E., Schacter, D., & Tulving, E. 1986. Learning and retention of computer-related vocabulary in memory-impaired patients: Method of vanishing cues. Journal of Clinical and Experimental Neuropsychology, 8, 292-312. Knight, R. G., & Wooles, I. M. 1980. Experimental investigation of chronic organic amnesia: A review. Psychological Bulletin, 88, 753-771. Kovner, R., Mattis, S., & Goldmeier, E. 1983. A technique for promoting robust free recall in chronic organic amnesia. Journal of Clinical Neuropsychology, 5, 65-71.
ROBUST FREE RECALL
157
Kovner, R., Mattis, S., & Pass, R. 1985. Some amnesic patients can freely recall large amounts of information in new contexts. Journal of Clinical and Experimental Neuropsychology,
7, 39.5-411.
Lezak, M. D. 1983. Neuropsychological assessment. New York: Oxford Press. 2nd ed. Mattis, S., & Kovner, R. 1984. Amnesia is as amnesia does: Toward another definition of the anterograde amnesias. In Larry R. Squire & Nelson Butters (Eds.), Nelrropsychology of memory. New York: Guilford Press. Paivio, A.. Yuille, J. C., & Madigan, S. 1968. Concreteness, imagery, and meaningfulness values for 925 nouns. Journal of Experimental Psychology Monograph, 76, (1, Pt. 2). Schacter, D., & Graf, P. 1986. Preserved learning in amnesic patients: Perspectives from research on direct priming. Journal of Clinical and Experimental Neuropsychology, 8, 727-143. Squire, L. R., & Shimamura, A. 1986. Characterizing amnesic patients for neurobehavioral study. Behaviorul Neuroscience, 100, 866-877. Winocur, G., Kinsbourne, M., & Moscovitch, M. 1981. The effect of cueing on release from proactive interference in Korsakoff amnesic patients. Journal of Experimental Psychology:
Human Learning
and Memory,
7, 56-65.