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Withdrawal seizures in black and white alcoholic patients: Intellectual and neuropsychological sequelae
Drug and Alcohol Dependence, 12 (1983) 349-354 Elsevier Scientific Publishers Ireland Ltd.
349
WITHDRAWAL SEIZURES IN BLACK AND WHITE ALCOHOLIC PATIENTS: INTELLECTUAL AND NEUROPSYCHOLOGICAL SEQUELAE*
GERALD GOLDSTEIN**, RALPH E. TARTER, ALTERMAN and EDWARD PETRARULO
CAROLYN
SHELLY, ARTHUR I.
VA Medical Center, Highland Drive, Pittsburgh, PA and University of Pittsburgh School of Medicine, Pittsburgh, PA (U.S.A.)
SUMMARY
An investigation was made of whether black alcoholics have a different response to having withdrawal seizures than white alcoholics, in terms of cognitive and other neuropsychological deficits. In a previous study it was found that white alcoholics with histories of withdrawal seizures did not demonstrate neuropsychological differences from white alcoholic patients without such histories. However, the apparently higher incidence of withdrawal seizures among blacks noted during screening of subjects for this study raised the question of whether the consequences of the seizure history might be different among blacks. The Halstead-Reitan Neuropsychological Test Battery was administered to 22 white and 20 black alcoholic inpatients. Half of each group had a history of withdrawal seizures while the other half did not. The results of the study indicated that on several tests, there were significant differences between black patients with and without seizure histories, but that was not the case for the white patients. Various possible causes for this finding are discussed. Key words: Neuropsychology
- Seizure disorders
- Halstead-Reitan
battery
INTRODUCTION
In a recent study of the neuropsychological consequences of withdrawal seizures in alcoholics, Tarter et al. [l] noted the possibility that there may be a higher incidence of seizures among black alcoholics compared to white *Indebtedness is expressed to the Veterans Administration for support of this research. **To whom reprint requests should be sent at: Research (151R), VA Medical Center, Highland Drive, Pittsburgh, PA 15206, U.S.A. 0376-8716/83/$03.00 o 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
350
alcoholics. There was a higher incidence of seizures in blacks who were screened for participation in that study as well as among subjects investigated by Fialkov [Z] in a South African investigation. Given this possibly higher incidence of withdrawal seizures among blacks, a question may be raised with regard to the possibility of relatively more severe neuropsychological consequences of seizures among blacks as compared with whites. Thus, Tarter et al. [l] demonstrated that presence or absence of withdrawal seizures was unrelated to neuropsychological or intellectual capacity in white alcoholics, but it is unknown if the same absence of a relationship holds among blacks. The present study was designed to determine if black and white alcoholics differ with regard to degree of neuropsychological and intellectual impairment as related to the presence or absence of withdrawal seizures. Inasmuch as neuropsychological capacity in alcoholics has been found to be predictive of treatment outcome [ 31 as well as future employability [ 41, it is possible that demonstrating an association with withdrawal seizures could lead to the use of this clinical disorder as an index for potential treatment success and psychosocial adjustment. METHOD
Subjects
The study sample consisted of 42 male inpatient alcoholics. Twenty-two were white and twenty black. Half of the subjects in each group had medically documented histories of at least one withdrawal seizure, while the remaining half had verified seizure-free histories. Pertinent age and education data are presented in Table I. Analyses of variance revealed no significant differences among the groups for age (F(3, 38) = 1.42, P > 0.05) or years of education (F(3, 38) = 1.21, P > 0.05). None of the subjects had a history of significant head trauma or other neurological disorders that could have caused seizures. They all had sufficiently lengthy and severe histories of alcoholism to require inpatient treatment for their alcoholism in a psychiatric facility, but none of them were psychotic. Thus, the four groups were equated for age, education and neurological history, and differed only with regard to race and presence or absence of withdrawal seizures. TABLE I AGE AND EDUCATION DATA FOR THE FOUR GROUPS Group
Black White Black White
Years of education
Age
seizures seizures non-seizures non-seizures
Mean
S.D.
Mean
S.D.
44.10 47.55 39.80 43.46
9.23 7.82 11.00 5.92
9.80 10.64 11.00 12.73
2.74 3.01 2.63 5.35
351
Procedure Following completion of detoxication, generally about two weeks following hospitalization, the subjects were administered a modified version of the Halstead-Reitan neuropsychological test battery [ 51 including the full Wechsler Adult Intelligence Scale (WAIS). The obtained data were analyzed by a series of 2 X 2 analyses of variance, with race and presence or absence of seizures as the two independent variables. RESULTS
Table II contains the means and standard deviations for all measures used, organized according to subgroup. The results of the analyses of variance are presented in Table III. It will be noted that the main effect for race was significant in several instances, but the seizure main effect was only significant for the Arithmetic, Vocabulary and Picture Arrangement only significant for the Arithmetic. Vocabulary and Picture Arrangement subtests of the WAIS, and for the location component of Halstead’s Tactual Performance Test. Significant interactions were found for WAIS Vocabulary, the total blocks score from the Tactual Performance Test, Trail making A, Finger Tapping and Finger Writing. Unlike the original study in which no significant differences were found between alcoholics with and without a seizure history, there were several significant differences in the present study. In all cases, the seizure group as a whole did worse than the nonseizure group. The significant interactions are of particular interest, since, with the exception of WAIS Vocabulary, large differences were noted between black subjects with and without seizure histories, but not between white subjects with and without seizure histories.
DISCUSSION
The major finding of this study is that black alcoholics with seizure histories do substantially more poorly than black alcoholics without such histories on certain intellectual and neuropsychological tests, whereas these differences were not observed among white alcoholics. A second finding of some interest is that, regardless of race, the Picture Arrangement subtest of the WAIS was performed more poorly by subjects with seizures than by subjects without seizures. This finding is consistent with the literature concerning the neuropsychological correlates of temporal lobe dysfunction [6--81. Indeed, Long and Hunter [9] found that Picture Arrangement was the only WAIS subtest that discriminated between patients with temporal lobe epilepsy and controls. Hence, it is unlikely that the impairment noted on Picture Arrangement occurred by chance. Rather, it is congruent with the documented association between limbicdiencephalic dysfunction and alcoholic withdrawal seizures [lo].
WAZS subtests
DEVIATIONS
Category test (errors) Tactual performance test (TPT), time TPT, blocks TPT, memory TPT, location Speech perception (errors) Rhythm errors Trailmaking A, time Trailmaking B, time Tapping (RH + LH) Finger agnosia (RH + LH errors) Finger writing (RH + LH errors) Grooved pegboard (RH + LH time)
Neuropsychological
Information Comprehension Atithmetic Similarities Digit Span Vocabulary Digit Symbol Picture Completion Block Design Picture Arrangement Object Assembly
tests
AND STANDARD
MEANS
Measure
II
TABLE
74.60 5.30 15.00 269.90
104.44 26.74 16.44 5.78 1.11 17.78 7.33 82.89 227.11 24.71 4.92 10.71 2.11 1.27 5.54 3.20 39.19 71.68 15.10 4.40 11.29 163.64
1.66 1.79 1.71 3.34 1.84 2.04 2.26 2.26 2.68 1.95 2.31
75.18 22.98 26.80 6.18 2.27 14.09 8.18 47.36 132.27 91.55 2.64 7.64 142.55
9.82 10.27 8.82 9.82 8.55 8.91 6.64 9.00 8.00 7.09 8.36
Mean
Mean
7.10 8.10 6.60 7.50 7.50 8.20 4.30 7.70 5.40 6.30 4.70
White Seizure S.D.
THE INTELLECTUAL
Black Seizure
Group
FOR
23.88 5.18 3.80 1.89 2.01 8.57 4.47 23.03 62.59 18.57 3.04 7.84 86.91
2.64 3.38 3.16 3.22 3.08 2.47 2.20 1.79 1.41 2.17 1.86
S.D.
81.50 22.51 25.10 5.50 2.30 18.60 5.80 45.30 152.50 85.70 5.00 7.20 217.80
8.70 7.60 8.30 8.40 8.00 8.20 6.30 8.30 8.30 8.60 6.30
Mean
Black Non-seizure
AND NEUROPSYCHOLOGICAL
28.44 5.83 7.37 2.22 1.83 13.71 5.05 25.10 101.26 15.76 6.83 6.96 119.37
2.29 1.65 2.41 4.14 3.46 1.48 4.11 2.79 3.34 2.91 3.16
S.D.
72.00 20.53 23.46 6.64 3.64 11.46 6.18 57.18 141.55 81.00 2.18 11.27 177.27
11.64 11.55 11.00 10.55 10.46 12.27 7.00 10.00 9.19 9.18 8.73
Mean
White Non-seizure
MEASURES
32.01 7.86 10.93 2.69 2.54 6.15 3.71 32.63 83.35 19.08 2.18 9.98 53.69
3.78 3.98 3.52 3.39 4.20 3.52 2.57 2.05 3.31 3.06 4.34
SD.
z
W
353 TABLE III ANALYSIS
OF VARIANCE
Measure
RESULTS FOR THE FOUR GROUPS Comparison Black vs. white
WAIS su btests Information Comprehension Arithmetic Similarities Digit span Vocabulary Digit symbol Picture completion Block design Picture arrangement Object assembly Neuropsychological tests Category test (errors) TPT, time TPT, blocks TPT, memory TPT, location Speech perception (errors) Rhythm (errors) Trailmaking A, time Trailmaking B, time Tapping (RH + LH) Finger agnosia (RH + LH errors) Finger writing (RH + LH errors) Grooved pegboard (RH + LH time)
Seizure vs. non-seizure
Interaction
F
P
F
P
F
4.19 11.42 7.97 4.19 2.97 9.39 2.93 4.71 9.79 0.75 10.23
<0.05 co.01
0.55 0.23 5.03 0.55 1.49 5.11 1.67 1.38 1.63 7.63 1.00
NS NS
0.01 0.96
co.05 NS NS < 0.05 NS NS NS
0.08 0.01 0.48 4.65 0.85 0.08 0.01 0.02 0.42
5.04 2.12 2.16 0.96 4.00 3.69 0.22 1.38 4.17 1.31
<0.05 NS NS NS NS NS NS NS <0.05 NS
1.75 2.88 0.73 0.08 4.22 0.13 1.86 1.64 1.37 0.00
NS NS NS NS co.05 NS NS NS NS NS
1.50 0.21 4.72 0.41 0.02 0.37 0.03 6.24 2.74 4.10
NS NS < 0.05 NS NS NS NS
4.07
<0.05
0.08
NS
0.00
NS
0.34
NS
0.41
NS
4.08
<0.05
5.92
<0.05
0.04
NS
1.58
NS
P
NS NS NS
NS
NS < 0.05 NS NS NS NS NS
The results generally indicate that blacks who suffer from withdrawal seizures develop more severe neuropsychological sequelae than whites. There are several possible explanations for this phenomenon. First, it is possible that blacks, for some reason, have a greater vulnerability to the effects of alcohol than whites. Alternatively, it is possible that economic privation results in consumption of lower grade beverages that contain more toxic congeners. A third reason may be that there is greater malnutrition or hepatic disease in blacks as a result of the combined effects of lifestyle and drinking pattern. Pristach et al. [ll] have indicated that
354
presence and severity of withdrawal syndromes are not completely predictable from alcohol tissue levels found immediately prior to withdrawal. Regardless of the causal mechanisms, however, the present findings may have implications for rehabilitation potential as it pertains to employability, social adjustment and success of treatment. Since neuropsychological capacity is predictive of outcome in these areas [ 3,4], the higher incidence of withdrawal seizures among blacks and its greater impact on cognitive abilities than those observed among whites may have significant implications for treatment prognosis and capacity to resume a productive lifestyle. REFERENCES 1 R.E. Tarter et al., J. Nerv. Ment. Dis., 171 (1983) 123. 2 M. Fialkov, S. Afr. Med. J., 52 (1977) 613. 3 O.A. Parsons and S.P. Farr, in: S.B. Filskov and T.J. Boll (Eds.), Handbook of Clinical Neuropsychology, Wiley-Interscience, New York, 1981, pp. 320-365. 4 R. Heaton and T. Crowley, in: S.B. Filskov and T.J. Boll (Eds.), Handbook of Clinical Neuropsychology, Wiley-Interscience, New York, 1981, pp. 481-525. 5 R.M. Reitan and L.A. Davison, Clinical Neruropsychology: Current status and applications, V.H. Winston, Washington, DC, 1974. 6 M. Lezak, Neuropsychological Assessment, Oxford University Press, New York, 1983. 7 R.M. Reitan, Percept. Mot. Skills, 9 (1959) 127. 8 J. McFie, Assessment of Organic Intellectual Impairment, Academic Press, London, 1975. 9 C.J. Long, and S.E. Hunter, Clin. Neuropsychol., 3 (1981) 16. 10 B. Segal et al., Q. J. Stud. Alcohol, 31 (1970) 587. 11 C.A. Pristach, C.M. Smith and R.B. Whitney, Drug Alcohol Depend., 11 (1983) 177.
349
WITHDRAWAL SEIZURES IN BLACK AND WHITE ALCOHOLIC PATIENTS: INTELLECTUAL AND NEUROPSYCHOLOGICAL SEQUELAE*
GERALD GOLDSTEIN**, RALPH E. TARTER, ALTERMAN and EDWARD PETRARULO
CAROLYN
SHELLY, ARTHUR I.
VA Medical Center, Highland Drive, Pittsburgh, PA and University of Pittsburgh School of Medicine, Pittsburgh, PA (U.S.A.)
SUMMARY
An investigation was made of whether black alcoholics have a different response to having withdrawal seizures than white alcoholics, in terms of cognitive and other neuropsychological deficits. In a previous study it was found that white alcoholics with histories of withdrawal seizures did not demonstrate neuropsychological differences from white alcoholic patients without such histories. However, the apparently higher incidence of withdrawal seizures among blacks noted during screening of subjects for this study raised the question of whether the consequences of the seizure history might be different among blacks. The Halstead-Reitan Neuropsychological Test Battery was administered to 22 white and 20 black alcoholic inpatients. Half of each group had a history of withdrawal seizures while the other half did not. The results of the study indicated that on several tests, there were significant differences between black patients with and without seizure histories, but that was not the case for the white patients. Various possible causes for this finding are discussed. Key words: Neuropsychology
- Seizure disorders
- Halstead-Reitan
battery
INTRODUCTION
In a recent study of the neuropsychological consequences of withdrawal seizures in alcoholics, Tarter et al. [l] noted the possibility that there may be a higher incidence of seizures among black alcoholics compared to white *Indebtedness is expressed to the Veterans Administration for support of this research. **To whom reprint requests should be sent at: Research (151R), VA Medical Center, Highland Drive, Pittsburgh, PA 15206, U.S.A. 0376-8716/83/$03.00 o 1983 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
350
alcoholics. There was a higher incidence of seizures in blacks who were screened for participation in that study as well as among subjects investigated by Fialkov [Z] in a South African investigation. Given this possibly higher incidence of withdrawal seizures among blacks, a question may be raised with regard to the possibility of relatively more severe neuropsychological consequences of seizures among blacks as compared with whites. Thus, Tarter et al. [l] demonstrated that presence or absence of withdrawal seizures was unrelated to neuropsychological or intellectual capacity in white alcoholics, but it is unknown if the same absence of a relationship holds among blacks. The present study was designed to determine if black and white alcoholics differ with regard to degree of neuropsychological and intellectual impairment as related to the presence or absence of withdrawal seizures. Inasmuch as neuropsychological capacity in alcoholics has been found to be predictive of treatment outcome [ 31 as well as future employability [ 41, it is possible that demonstrating an association with withdrawal seizures could lead to the use of this clinical disorder as an index for potential treatment success and psychosocial adjustment. METHOD
Subjects
The study sample consisted of 42 male inpatient alcoholics. Twenty-two were white and twenty black. Half of the subjects in each group had medically documented histories of at least one withdrawal seizure, while the remaining half had verified seizure-free histories. Pertinent age and education data are presented in Table I. Analyses of variance revealed no significant differences among the groups for age (F(3, 38) = 1.42, P > 0.05) or years of education (F(3, 38) = 1.21, P > 0.05). None of the subjects had a history of significant head trauma or other neurological disorders that could have caused seizures. They all had sufficiently lengthy and severe histories of alcoholism to require inpatient treatment for their alcoholism in a psychiatric facility, but none of them were psychotic. Thus, the four groups were equated for age, education and neurological history, and differed only with regard to race and presence or absence of withdrawal seizures. TABLE I AGE AND EDUCATION DATA FOR THE FOUR GROUPS Group
Black White Black White
Years of education
Age
seizures seizures non-seizures non-seizures
Mean
S.D.
Mean
S.D.
44.10 47.55 39.80 43.46
9.23 7.82 11.00 5.92
9.80 10.64 11.00 12.73
2.74 3.01 2.63 5.35
351
Procedure Following completion of detoxication, generally about two weeks following hospitalization, the subjects were administered a modified version of the Halstead-Reitan neuropsychological test battery [ 51 including the full Wechsler Adult Intelligence Scale (WAIS). The obtained data were analyzed by a series of 2 X 2 analyses of variance, with race and presence or absence of seizures as the two independent variables. RESULTS
Table II contains the means and standard deviations for all measures used, organized according to subgroup. The results of the analyses of variance are presented in Table III. It will be noted that the main effect for race was significant in several instances, but the seizure main effect was only significant for the Arithmetic, Vocabulary and Picture Arrangement only significant for the Arithmetic. Vocabulary and Picture Arrangement subtests of the WAIS, and for the location component of Halstead’s Tactual Performance Test. Significant interactions were found for WAIS Vocabulary, the total blocks score from the Tactual Performance Test, Trail making A, Finger Tapping and Finger Writing. Unlike the original study in which no significant differences were found between alcoholics with and without a seizure history, there were several significant differences in the present study. In all cases, the seizure group as a whole did worse than the nonseizure group. The significant interactions are of particular interest, since, with the exception of WAIS Vocabulary, large differences were noted between black subjects with and without seizure histories, but not between white subjects with and without seizure histories.
DISCUSSION
The major finding of this study is that black alcoholics with seizure histories do substantially more poorly than black alcoholics without such histories on certain intellectual and neuropsychological tests, whereas these differences were not observed among white alcoholics. A second finding of some interest is that, regardless of race, the Picture Arrangement subtest of the WAIS was performed more poorly by subjects with seizures than by subjects without seizures. This finding is consistent with the literature concerning the neuropsychological correlates of temporal lobe dysfunction [6--81. Indeed, Long and Hunter [9] found that Picture Arrangement was the only WAIS subtest that discriminated between patients with temporal lobe epilepsy and controls. Hence, it is unlikely that the impairment noted on Picture Arrangement occurred by chance. Rather, it is congruent with the documented association between limbicdiencephalic dysfunction and alcoholic withdrawal seizures [lo].
WAZS subtests
DEVIATIONS
Category test (errors) Tactual performance test (TPT), time TPT, blocks TPT, memory TPT, location Speech perception (errors) Rhythm errors Trailmaking A, time Trailmaking B, time Tapping (RH + LH) Finger agnosia (RH + LH errors) Finger writing (RH + LH errors) Grooved pegboard (RH + LH time)
Neuropsychological
Information Comprehension Atithmetic Similarities Digit Span Vocabulary Digit Symbol Picture Completion Block Design Picture Arrangement Object Assembly
tests
AND STANDARD
MEANS
Measure
II
TABLE
74.60 5.30 15.00 269.90
104.44 26.74 16.44 5.78 1.11 17.78 7.33 82.89 227.11 24.71 4.92 10.71 2.11 1.27 5.54 3.20 39.19 71.68 15.10 4.40 11.29 163.64
1.66 1.79 1.71 3.34 1.84 2.04 2.26 2.26 2.68 1.95 2.31
75.18 22.98 26.80 6.18 2.27 14.09 8.18 47.36 132.27 91.55 2.64 7.64 142.55
9.82 10.27 8.82 9.82 8.55 8.91 6.64 9.00 8.00 7.09 8.36
Mean
Mean
7.10 8.10 6.60 7.50 7.50 8.20 4.30 7.70 5.40 6.30 4.70
White Seizure S.D.
THE INTELLECTUAL
Black Seizure
Group
FOR
23.88 5.18 3.80 1.89 2.01 8.57 4.47 23.03 62.59 18.57 3.04 7.84 86.91
2.64 3.38 3.16 3.22 3.08 2.47 2.20 1.79 1.41 2.17 1.86
S.D.
81.50 22.51 25.10 5.50 2.30 18.60 5.80 45.30 152.50 85.70 5.00 7.20 217.80
8.70 7.60 8.30 8.40 8.00 8.20 6.30 8.30 8.30 8.60 6.30
Mean
Black Non-seizure
AND NEUROPSYCHOLOGICAL
28.44 5.83 7.37 2.22 1.83 13.71 5.05 25.10 101.26 15.76 6.83 6.96 119.37
2.29 1.65 2.41 4.14 3.46 1.48 4.11 2.79 3.34 2.91 3.16
S.D.
72.00 20.53 23.46 6.64 3.64 11.46 6.18 57.18 141.55 81.00 2.18 11.27 177.27
11.64 11.55 11.00 10.55 10.46 12.27 7.00 10.00 9.19 9.18 8.73
Mean
White Non-seizure
MEASURES
32.01 7.86 10.93 2.69 2.54 6.15 3.71 32.63 83.35 19.08 2.18 9.98 53.69
3.78 3.98 3.52 3.39 4.20 3.52 2.57 2.05 3.31 3.06 4.34
SD.
z
W
353 TABLE III ANALYSIS
OF VARIANCE
Measure
RESULTS FOR THE FOUR GROUPS Comparison Black vs. white
WAIS su btests Information Comprehension Arithmetic Similarities Digit span Vocabulary Digit symbol Picture completion Block design Picture arrangement Object assembly Neuropsychological tests Category test (errors) TPT, time TPT, blocks TPT, memory TPT, location Speech perception (errors) Rhythm (errors) Trailmaking A, time Trailmaking B, time Tapping (RH + LH) Finger agnosia (RH + LH errors) Finger writing (RH + LH errors) Grooved pegboard (RH + LH time)
Seizure vs. non-seizure
Interaction
F
P
F
P
F
4.19 11.42 7.97 4.19 2.97 9.39 2.93 4.71 9.79 0.75 10.23
<0.05 co.01
0.55 0.23 5.03 0.55 1.49 5.11 1.67 1.38 1.63 7.63 1.00
NS NS
0.01 0.96
co.05 NS NS < 0.05 NS NS NS
0.08 0.01 0.48 4.65 0.85 0.08 0.01 0.02 0.42
5.04 2.12 2.16 0.96 4.00 3.69 0.22 1.38 4.17 1.31
<0.05 NS NS NS NS NS NS NS <0.05 NS
1.75 2.88 0.73 0.08 4.22 0.13 1.86 1.64 1.37 0.00
NS NS NS NS co.05 NS NS NS NS NS
1.50 0.21 4.72 0.41 0.02 0.37 0.03 6.24 2.74 4.10
NS NS < 0.05 NS NS NS NS
4.07
<0.05
0.08
NS
0.00
NS
0.34
NS
0.41
NS
4.08
<0.05
5.92
<0.05
0.04
NS
1.58
NS
P
NS NS NS
NS
NS < 0.05 NS NS NS NS NS
The results generally indicate that blacks who suffer from withdrawal seizures develop more severe neuropsychological sequelae than whites. There are several possible explanations for this phenomenon. First, it is possible that blacks, for some reason, have a greater vulnerability to the effects of alcohol than whites. Alternatively, it is possible that economic privation results in consumption of lower grade beverages that contain more toxic congeners. A third reason may be that there is greater malnutrition or hepatic disease in blacks as a result of the combined effects of lifestyle and drinking pattern. Pristach et al. [ll] have indicated that
354
presence and severity of withdrawal syndromes are not completely predictable from alcohol tissue levels found immediately prior to withdrawal. Regardless of the causal mechanisms, however, the present findings may have implications for rehabilitation potential as it pertains to employability, social adjustment and success of treatment. Since neuropsychological capacity is predictive of outcome in these areas [ 3,4], the higher incidence of withdrawal seizures among blacks and its greater impact on cognitive abilities than those observed among whites may have significant implications for treatment prognosis and capacity to resume a productive lifestyle. REFERENCES 1 R.E. Tarter et al., J. Nerv. Ment. Dis., 171 (1983) 123. 2 M. Fialkov, S. Afr. Med. J., 52 (1977) 613. 3 O.A. Parsons and S.P. Farr, in: S.B. Filskov and T.J. Boll (Eds.), Handbook of Clinical Neuropsychology, Wiley-Interscience, New York, 1981, pp. 320-365. 4 R. Heaton and T. Crowley, in: S.B. Filskov and T.J. Boll (Eds.), Handbook of Clinical Neuropsychology, Wiley-Interscience, New York, 1981, pp. 481-525. 5 R.M. Reitan and L.A. Davison, Clinical Neruropsychology: Current status and applications, V.H. Winston, Washington, DC, 1974. 6 M. Lezak, Neuropsychological Assessment, Oxford University Press, New York, 1983. 7 R.M. Reitan, Percept. Mot. Skills, 9 (1959) 127. 8 J. McFie, Assessment of Organic Intellectual Impairment, Academic Press, London, 1975. 9 C.J. Long, and S.E. Hunter, Clin. Neuropsychol., 3 (1981) 16. 10 B. Segal et al., Q. J. Stud. Alcohol, 31 (1970) 587. 11 C.A. Pristach, C.M. Smith and R.B. Whitney, Drug Alcohol Depend., 11 (1983) 177.