Construction and Self-monitoring

WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought.  Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia.  How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head.  It requires conceptualization, motor control and visual motor integration for success.  The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback.  The task of constructing a bicycle is a screening for higher order deficits.  Like the clock drawing it requires planning, organization, even mechanical awareness.  Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal.  Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)



“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships”    Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly.  the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring.  In a published blog the concept is described.  It is the process of repeating the same response over and over without awareness.

Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.

Clock of the Week June 6

Westborough, MA June 6, 2017 The clock of the week is depicted below.  It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital.  I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine.  I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient.  It was drawn by a 93-year old male with congestive heart

SLP_93 YOScan
Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s.  This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient.  The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well.  I once had a patient draw and elaborate grandfather clock fit for a castle.  The clock face became secondary and insignificant – for him.  The clock is a regular feature here at Concussion Assessment and Management.  
Anyone can submit a clock for consideration of the clock of the week.  Upload to my email address: – No identifying HIPPA protected information please but a brief overview is always helpful. 

Mayo Clinic. Taken June 6, 2017

Delirium: sudden onset often lingering emotional impact

Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.  STAT Boston Globe taken 10-17-2016
Try as he might a patient with delirium cannot complete simple tasks according to Sefton.

Perseveration, severation, eration, ation

WESTBOROUGH, MA October 14, 2016 What does the term ‘to perseverate’ refer to in clinical terms.  The media attached below will illustrate the concept of perseveration in its clinical presentation. The patient was asked to copy her name.  A model was presented for her by the examiner. Most people have control over behavior through a series of feedback loops that become active in the brain that allow for anticipatory awareness and behavioral prospective as a person reaches full cognitive maturity.  Patients who are recovering from right hemisphere lesions often exhibit the pattern

Patient asked to copy her name – Frances

of repetition without regard for how appropriate the pattern may be in respect to the task demand. You can see that the patient draws what appear to be tee pee shaped figures and two horizontal lines – perhaps a modified upper case A.  Meanwhile, she repeated the figure until she ran out of paper at the bottom margin.  In blogs already published I have mentioned the term perseveration and made an effort to illustrate its unusual presentation. One can see in the feature image a circular pattern of zeros as a patient attempted the clock drawing.  The patient got stuck making the number 0.  In the recent blog on this topic, I posted a video for the readers use that shows one case of perseveration in an older patient drawing circles over and over.


The term refers to the pattern of repeated motor movement in spite of the indication (or feedback) that the response is no longer needed or is inappropriate.  As you can see by this drawing the individual continued to make the same pattern over and over without regard for the task I had assigned – copy your name.

Treatment from serious stroke require months of cognitive rehabilitation in addition to physical and occupational therapy.  patients must be taught to recognize their cognitive vulnerability to errors like this.  As recovery is made most patients establish improved self-monitoring to compensate for their weaknesses. But some fail to re-establish the feedback loops and awareness that allow them to live in the world with the immediate awareness that once is enough and it is okay to stop.

Perseveration: Often seen in concussion – in short duration before recovery

WESTBOROUGH, MA July 23, 2016 Perseveration results from a change in cognitive status often seen in athletes with concussion. It is most often manifest when an athlete says or does the same thing over and over without realizing it. In some cases the athlete will make an effort to cover for themselves expecting that no one will notice that anything is amiss. Not so fast.  The last one to notice that anything is wrong is the athlete with a concussed brain.  Everyone else notices but not him.  Recently the NFL has made it mandatory for a teammate who suspects that a teammate has sustained a concussion must say something to the coaches or trainer.

In patients with concussion the confusion evaporates quickly generally within minutes to hours.  The video shown here depicts a case of perseveration that is more severe.  It is an older patient who sustained a fall and is quite altered. The video illustrates a case of altered mental status resulting in perseverative drawing in circles.  In general, patients who are older have a slower recovery than younger ones. This video shows the stark lack of self-monitoring as the patient attempts to construct a simple clock.

This video was put together by the Neuropsychology Service at Whittier Rehabilitation Hospital in Westborough, MA USA


Bike of the week – acquired brain injury

Draw a bike – How does it work?

WESTBOROUGH, MA June 6, 2016 The Bike of the week is drawn by a 86-year old man who is undergoing inpatient rehabilitation for an acquired brain injury and stroke. Actually I rarely publish the drawings made by patients I see unless I am going through a dry spell of interesting clocks.  The man who drew this bicycle was independent prior to a fall and driving.  In this case, there was a a fall 2 months ago – in April 2016 from which he largely recovered.  He underwent lab studies and a C-T scan of his brain being diagnosed with subdural hematoma (SDH).  The C-T scan revealed a collection of blood in the frontal part of his brain known as a subdural hematoma (SDH) often associated with brain trauma from a fall or motor vehicle crash.  The patient in this case had fallen in his bathroom. He had been prescribed a blood thinner and his atrial fibrillation which was stopped.  These levels were supratherapeutic – too high making him at high risk for bleeding – in this case in his brain. He was taken off the blood thinner in the weeks following the traumatic injury to allow the bleeding in his brain to be controlled. In late May, 2016, he was found at home to be slurring his words and demonstrating right hand weakness. He was rushed to Cape Cod Hospital and diagnosed with a left MCA ischemic stroke and he was treated conservatively.

Bleeding on the brain is a life threatening condition that will eventually result in herniation of brain tissue and death unless it is controlled.  Trauma can lead to edema or swelling of brain tissue.  In many cases, neurosurgery is required to remove subdural blood allowing space in the skull for the brain to swell as much as needed to recover.  In some rare cases, the part of the skull is actually removed to allow for brain swelling.  By removing a portion of the skull the brain tissue does not efface ipsilateral tissue or cause herniation by crowding out other viable brain tissue.