Documente Academic
Documente Profesional
Documente Cultură
0028-3932/84 $3.00+0.00
1984PergamonPressLtd.
VARIETIES OF PERSEVERATION
JENNIFER SANDSON a n d MARTIN L. ALBERT
Department of Neurology, Boston University Medical School and Boston Veterans Administration Medical
Center, 150 South Huntington Avenue, Boston, MA 02130, U.S.A., and Department of Psychology,
Cornell University, Ithaca, NY 14850, U.S.A.
INTRODUCTION
THE TERMperseveration is generally used to describe any continuation or recurrence of
experience or activity without the appropriate stimulus. N~SSER [29] noted perseveration in
pathological conditions as diverse as psychosis and aphasia. He considered all forms of
perseverative behavior to be reflections of one undetermined underlying deficit.
LIEPMANN [22] provided the first classification schema for perseverative behaviors, dividing them into tonic, clonic and intentional types. A patient with tonic perseveration, as defined by Liepmann, might have difficulty releasing the hand that he had been instructed to
shake. Such a patient remains stuck, unable to relax, in the final stages of a completed action.
With clonic perseveration a patient continues to repeat the action in which he is engaged.
When asked to draw a series of three-looped figures, for example, a patient with clonic
perseveration is unable to limit his drawing to just three loops. Intentional perseveration is
the unintentional repetition of a previously emitted response when a new response is
intended. Liepmann cited as an example the patient who correctly blows out a match and
then repeats the blowing motion to subsequent stimuli. Liepmann believed both clonic and
intentional perseveration to be "ideational" in origin, "there being an impasse in the area of
sensory preparation of movement with the result that new stimuli can excite a previous idea
and the movement caused thereby" p. 572.
Subsequent taxonomies of perseveration have dropped the clonic form, considering
In the spring of 1983, a few months before his death, Henry H6caen and I discussed the important role of
perseveration in behavioral neurology and neuropsychology. We agreed that a systematic analysis of perseveration,
its influence on observed neurobehaviorai deficits and its underlying mechanisms was warranted, and that the time
was ripe for such a study. We discussed hypotheses which might serve as a framework for this new study. The
following theoretical statement, developed subsequently in Boston with Jennifer Sandson, was inspired by those
discussions--MLA.
715
716
s u s t a i n e d a c t i v i t y as s e p a r a t e f r o m b e h a v i o r s o f r e p e t i t i o n , a n d m a n y h a v e c o n s i d e r e d
p e r s e v e r a t i o n t o r e p r e s e n t a u n i t a r y n e u r o p s y c h o l o g i c a l deficit. D i f f e r e n t t a x o n o m i e s
p r o p o s e d f o r p e r s e v e r a t i o n a r e p r e s e n t e d in T a b l e 1.
O u r c l i n i c a l e x p e r i e n c e , t o g e t h e r w i t h a d e t a i l e d r e v i e w o f t h e l i t e r a t u r e , r e v e a l s the n e e d
for a new system for classifying perseverative behavior. We suggest that categories within
this p r o p o s e d n e w c l a s s i f i c a t i o n s c h e m e a r e d i s t i n c t at b o t h the p h e n o m e n o l o g i c a l a n d the
Definition
Example
LIEPMANN [22]
Tonic
Clonic
Intentional
inappropriate repetition of a
previously emitted response to a
subsequent stimulus
stimulus x -. response a
stimulus y ~ response b
stimulus z -. response a
LURI^ [23]
Efferent motor
pathological inertia of a
previously emitted response
Perseveration due to
impairment in the program of
action
Compulsive repetition
inappropriate repetition of a
behavior
Impairment of switching
repetition of an immediately
preceding response to the
subsequent stimulus
Ideational
spontaneous recurrence of a
behavior after one or more
intervening stimuli
Repetitious
stimulus x ~ response x
stimulus b -. response x
as well as AbcdAefA on
attempting the alphabet :
Continuous
continuation of a response
beyond the point of completion
with no intervening stimuli
Stuck
YAMADORI[38]
fu-to-ko-ro-ga-ta-ma (dagger)-fu-to-ga-ra-mi (nonsense)
on second try
fu-t o-ko-ro-ga-ta-na -,
fu-to-ga-ra-mi
717
VARIETIES OF PERSEVERATION
Table l---continued
Type of perseveration
Definition
Example
Immediate
nu-ka-ni-ku-gi (a proverbt--,
nu-ka-niku-gi
ma-ke-ru-ga-ka-chi
{an unrelated proverb~--,
ma-ke-ru-ku-gioga (nonsense)
Delayed
nu-ka-ni-ku-gi -~
nu-ka-ni-ku-gi
ma-ke-ru-ga-ka-chi --*
ma-ke-ru-ga-ka-chi
mi-ka-ra-de-ta-sa-bi
mi-ka-ra-de-ta-ku-gi
immediate recurrence of a
previously emitted response to the
subsequent stimulus
Intrusion
no examples given
process levels, and quite possibly at the anatomical level as well. In support of this argument
we shall first present evidence for the three independent categories within the taxonomy: (1)
continuous and inappropriate repetition of a current behavior (continuous perseveration);
(2) continuous and inappropriate maintenance of a current set or framework (stuck-in-set
perseveration); and (3) unintentional repetition, after cessation, of a previously emitted
response to a subsequent stimulus (recurrent perseveration). Recurrent perseveration, in
turn, can be either immediate or delayed, depending on whether there have been intervening
stimuli between the original and perseverated responses. We shall then present evidence in
support of the three distinct neuropsychological process deficits which we believe underlie
the different clinical forms. The process deficit in recurrent perseveration involves a failure of
the usual inhibition of memory traces. In stuck-in-set perseveration it involves a breakdown
in executive functioning such that actions become dissociated from intent. In continuous
perseveration it involves a disturbance in motor output characterized by post-facilitation of
motor impulses. Neuroanatomical distinctions between subject groups exhibiting the
different syndromes will be noted throughout. Lastly, we shall present examples of each
perseverative syndrome.
EVIDENCE FOR A NEW TAXONOMY OF PERSEVERATION
Perseveration on tests requiring attention and cognitive flexibility has traditionally been
associated with frontal lobe lesions (see Table 2). This preservation, in both monkeys and
humans, is almost always of the stuck-in-set type. Adult monkeys with orbitofrontal lesions,
for example, are severely impaired on tests such as delayed alternation and object
discrimination reversal which have a large alternation component. These monkeys are not
impaired, however, on visual discrimination or delayed response tasks which require spatial
abilities or memory alone 1-12, 13, 28]. Humans with unilateral left or right frontal lobe
718
Major findings
MlSHKIN [28]
Monkeys with orbital and
dorsolateral frontal lesions
BUTTER 17]
Monkeys with total orbital,
posteromedial orbital, lateral
orbital, anterior orbital and
dorsolateral lesions
719
VARIETIES OF PERSEVERAT1ON
Table 2---continued
Subjects
Major findings
HUDSON[18]
the patient perseverated on tests
of proprioeeption and
stereognosis. Perseverations were
sometimes carried over from one
modality to another, resulting in
bizarre behavior. The patient's
drawing of a cat was particularly
notable for its incorporation of
the features of a man from the
previous assignment. Writing
showed perseveration of words
and consonants.
Lulu^ [23]
there are two distinct types of
motor perseveration.
720
unable to perform without perseveration any series of motor actions such as drawing
alternating shapes or performing multiple movements to command. Tasks in which the
required movement differed from the examiner's signal (e.g. raise your hand when I knock)
were particularly difficult. Similar perseveration was noted in writing and in calculation and
was not improved with visual example. The patient, however, showed no evidence of
compulsive (continuous) movements and was able to stop an initiated action appropriately.
Stuck-in-set perseveration has also been observed in patients with Parkinson's disease [20]
and in dementia of undetermined etiology [9].
Perseveration is also common in aphasia, where it is seen on a variety of verbal and nonverbal tasks (see Table 3). Most perseveration in aphasia seems to be of the recurrent type.
ALLISONand HURWITZ [2], for example, found that 16 of 24 aphasic subjects perseverated
on at least one of a series of tasks, most of this perseveration consisting of repetition of a
previously emitted response to a subsequent stimulus, such as on a visual naming task.
Perseveration was also common in response to simple verbal commands, in reversing
automatic series and in spontaneous speech.
HELMICK and BERG [17] administered a variety of tasks to both right- and lefthemisphere-damaged (aphasic and non-aphasic) patients. Significantly more perseveration
was found in the language-disturbed left-hemisphere-damaged patients than in the other
groups. Perseveration followed the presentation of a subsequent stimulus 66% of the
time. MATEER[24] reported significantly more perseveration, largely delayed, in aphasics on
a task involving imitation of multiple oral movements than in right hemisphere controls.
YAMADORI[38] reported perseveration in 33 of 38 aphasic subjects on a verbal repetition
task. Again, most of the perseverations occurred after presentation of the next stimulus.
There was no correlation between perseveration and type or severity of the aphasic deficit.
BUCKINGHAMel d . [6] analyzed both spontaneous and elicited speech samples from two
patients with jargon aphasia due to posterior parietal lesions. Delayed perseverations were
found to be quite frequent and to involve single words most often. The perseverate was
sometimes a slightly altered version of the original utterance and sometimes a phonological,
lexical or semantic blend. SHINDLERel al. [34] reported that 83 ~o of Wernicke's, 5030 of
Broca's and 38 /oofanomic aphasics made at least one delayed perseverative error on a series
of three verbal tests. While continuous perseverations did occur occasionally, they were
significantly less frequent. There was no correlation between the two types of perseveration.
Recurrent perseveration is also common in patients with dementia, especially senile
dementia of the Alzheimer's type. FULD et al. [10] reported that 88~ of patients with
Alzheimer's disease and 57 9o of patients with multi-infarct dementia produced at least one
delayed perseveration on a neuropsychological battery. SHINDLER et al. [34] reported
recurrent perseveration in 55 0 of patients with Alzheimer's disease, 40 ~ with multi-infarct
dementia and 20 ~o with normal-pressure hydrocephalus.
Continuous perseveration is best exemplified by LUmA'S[23] case report of a woman with
a massive tumor involving both frontal lobes and the basal ganglia. This patient had no
difficulty switching from one activity to the next or carrying out conditioned responses to
verbal instructions. When asked to draw a circle, however, she made multiple circular
movements and was unable to stop. Similar continuations were observed with writing and
with tapping. Continuous perseveration has been reported in schizophrenia [9] and in
normal-pressure hydrocephalus [34]. It is also cited occasionally in aphasia (e.g. [17]), but
only in cases where the possibility of subcortical damage has not been definitely ruled out.
Various combinations of the perseverative syndromes are observed in many neurological
conditions. In addition, normal children under 5 yr show more perseverative behavior
721
VARIETIES OF PERSEVERATION
Tasks used
Major findings
HALVERN [15]
33 dysphasic patients of mixed
etiology; unknown lesions
MATEER [24]
20 aphasic patients: 8 nonfluent, 12 fluent; 21 nonaphasic left hemisphere
patients; 21 right hemisphere
patients; 27 controls
722
Table 3 - - c o n t i n u e d
Subjects
Tasks used
Major findings
YAMADORI[38]
38 aphasic patients: 24
anterior, 14 posterior; mixed
etiology
Jargon aphasics
20 aphasic patients: 6
Wernicke's, 8 anomic, 6
Broca's
83 ~o of Wernicke's, 50% of
Broca's and 38 % of anomic
aphasics made at least one
perseverative error. Perseveration
correlated positively with naming.
Intrusions correlated positively
with poor hygiene and Iogorrhea
and negatively with WMS
information, idiom comprehension and WMS verbal memory.
There was no correlation between
perseverations and intrusions.
(of the stuck-in-set type) than older children [32]. Normal elderly persons on a task of word
list generation perseverate, as do normal young adults in spontaneous speech. It is
interesting, however, that perseveration is very rarely reported after focal right hemisphere
damage. See Table 4 for an overview of perseveration in the neuropsychological literature.
EXPLANATORY THEORIES OF PERSEVERATION
Many different accounts of perseveration have been proposed (see Table 5 for a
summary). None of these accounts, however, is adequate to explain all three perseverative
syndromes. GOLDSTEIN [14] claimed that perseveration was attributable to a catastrophic
VARIETIESOF PERSEVERATION
723
Table 4. Perseveration in neurology and neuropsychology (excluding reports in aphasia and focal frontal lesions)
Subjects
Tasks used
Major findings
Dementia
SHINDLER,et aL
[34]
55% of patients with SDAT, 407,0
of patients with MID and 20}o of
patients with NPH made at least
one intrusion. Patients with NPH
produced significantly more
perseverations than the other
groups. Perseverations correlated
positively with confabulations,
easy frustration, poor hygiene,
laconic speech and hostility. They
correlated negatively with WMS
information scores and Word
Association performance. There
was no correlation between
intrusions and any other
psychometric measure.
Parkinson's Disease
724
Table 4---continued
Subjects
Tasks used
Major findings
Schizophrenia
SIEGEL et al. [35]
30 schizopherenic patients: 15
hospitalized, 15 out-patient
KorsakofJ's disease
OSCAR-BERMAN et al. [30]
12 Korsakoff patients; 15
Huntington's disease patients;
11 aphasics; 13 alcoholic
controls
Autistic children
Boocnl~g [4]
21 autistic children; 21
controls matched for nonverbal ability
VARIETIES OF
PERSEVERATION
725
Table 4--continued
Subjects
Tasks used
Major findings
Normal children
ROSE [32]
children under 4 yr; older
children
Stutterers
SAYLES[33]
23 male stutterers; 25 control
college students
Normal elderly
Normal adults
GARRETT [11]
The speech errors of young adults
contain perseverations of segments,
words and phrases.
726
[ref.]
Proposed to explain
all forms of perseverativebehavior
perseveration in frontal lobe patients
continuous repetitions
an inability to switch activities
verbal perseveration in aphasia
some verbal perseveration in aphasia
perseveration on tasks involvinga variable reinforcement
schedule in Korsakoff's patients
delayed verbal perseverations
verbal perseverationin aphasia and dementia
visual recurrence
palinopsia
visual perseveration
verbal formulation take time and that subsequent stimuli are normally inhibited, a shutter is
closed, until processing is complete. This processing, however, may be considerably slowed
in aphasics, resulting in a longer inattentive period. When a response to an unattended
stimulus is called for, the aphasic m a y produce the name of the last attended item.
There are several important problems with Wepman's account, even within the verbal
modality to which it is restricted. First, it does not explain delayed perseverations. Second, it
does not account for the fact that verbal perseverations are frequently neologistic, blends or
contextually irrelevant. Third, aphasics perseverate in spontaneous speech when they can
permit themselves sufficient processing time. Fourth, changing the modality of input or of
response sometimes reduces perseveration. If the perseveration were caused by the closing of
an attentional shutter, modality should have no effect, as the stimulus should never be
encoded. Lastly, Wepman reports verbal perseveration on tasks where subsequent stimuli
are not presented until previous stimuli have been responded to and the shutter theoretically
opened. Aside from the occurrence of verbal perseveration, Wepman offers no evidence for a
disorder of attention in aphasics who perseverate. Wepman's observation that perseveration
may constitute a significant part of the aphasic patient's deficit is, however, extremely
important.
LEICESTER et al. [21] make the observation that some, although certainly not all,
perseverative behavior may be due to prior reinforcement and some to use of irrelevant
stimulus parameters. These particular perseverations can be explained in terms of normal
behavioral principles and do not require any abnormal physiology. They offer no
explanation, though, of why their aphasic subjects were more sensitive to these factors than
controls and why there is such variability in this sensitivity.
LURIA [23] proposed different underlying mechanisms for the two types of motor
perseveration which he observed. These two types are roughly equivalent to our continuous
and stuck-in-set categories respectively. In the first type, which he called efferent
VARIETIES OF PERSEVERATION
727
perseveration, I~oth the actual program of action and the ability to switch from one program
to another remain unimpaired while a "pathological inertia of the stimulus previously
initiated" results in compulsive repetition. Although never reported by Luria, efferent
perseveration also occurs in speech (e.g. as multiple repetitions of a final sound). Luria's term
"pathological inertia" seems to refer to a disturbance in motor output caused by abnormal
post-facilitation of motor impulses.
Luria's second type of perseveration, that manifest as an inability to switch from one
action to another, was viewed as the result of inertia of the program of action itself. Luria
noted that tasks on which verbal instructions conflict with kinesthetic or visual cues are
particularly likely to result in perseveration and emphasized the role of verbal regulation in
behavioral programming [16]. This type of perseveration seems to result from a dissociation
between action and intent. It is important to point out, though, that stuck-in-set
perseveration can occur on purely verbal tasks on which, for example, a subject might be
unable to change semantic categories.
A currently popular theory in the literature on verbal perseveration is that verbal
repetitions, of the type that we are calling recurrent perseverations, are a form of involuntary
recall resulting from the uncontrolled facilitatory activity of memory traces. According to
HUDSON [18], there is an extended period of augmentation of memory traces which must be
actively inhibited. It is a failure of this inhibition which results in the involuntary recall of
previous stimuli during attempts at subsequent recall. BUCKINGHAMet al. [6] also viewed
intentional perseveration as resulting from the abnormal post-activation of memory traces.
They claimed that new stimuli somehow become confused with still active older traces during
subsequent attempts at recall. YAMADORI[38] asserted that stuck, immediate and delayed
types of perseveration (see Table 1) reflect lessening degrees of post-activation. This
interpretation is problematic, though, as delayed perseveration would require the greatest
period of augmentation. Repetitions of the type that Yamadori calls immediate should be
classified as recurrent perseverations, as they are recurrences rather than continuations and
occur as often within one context as when switching tasks. It may be that the delayed subtype
of recurrent perseveration results from abnormal recall of post-facilitated items from a
short-term memory buffer while the immediate subtype reflects a failure, also due to postfacilitation, in the transfer of items to that buffer.
The post-facilitation of memory traces has also been proposed to explain palinopsia and
palinacousis [19, 36] and can account for recurrent perseverations on purely motor tasks.
Evidence cited in support of an underlying disturbance of memory includes the frequency
with which recurrent perseveration is observed in demented patients who have impaired
memory (e.g. [34]) and a negative correlation between delayed recurrent perseverations and
choline acetyl transferase levels [10]. DRACHMAN and LEAVITT [8] noted intrusions in
normal adults administered the anti-cholinergic agent scopolamine, which is known to
impair memory.
728
emitted response to a subsequent stimulus. The underlying process seems to involve a postfacilitation of memory traces. Recurrent perseveration is most common in aphasics with left
hemisphere lesions and in cases of dementia of the Alzheimer's type. Stuck-in-set
perseveration is the inappropriate maintenance of a current category or framework. Patients
with stuck-in-set perseveration have a disturbance in executive functioning such that actions
and goals became dissociated. It is most common in patients with frontal lobe pathology.
Continuous perseveration is the inappropriate repetition, without interruption, of a current
behavior. It seems to be caused by a disturbance in motor output and is most common in
patients with subcortical involvement.
CASE REPORTS
Stuck-in-set perseveration
J.K. is a 62-yr-old right-handed male admitted to the Aphasia/Neurobehavior Unit of the
Boston Veterans Administration Hospital for evaluation of dementia. He had no significant
medical history until approximately 1 yr prior to admission, when memory problems were
first noted. Since that time he has become progressively more irritable and has developed
trouble in walking. His voice has become slurred, hypophonic and raspy. A C T scan showed
moderate diffuse cortical atrophy; EEG was unremarkable.
The patient was alert and cooperative throughout the neuropsychological evaluation.
Language functions were significantly more impaired than visuospatial. In particular,
significant difficulties were found in object naming, word list generation, oral reading and
writing. Calculation ability was severely impaired due to both computational errors and a
failure to carry. Writing numbers to dictation was also poor. Memory deficits were observed
for both remote and new verbal information. Immediate recall of non-verbal figures was
grossly accurate. Pull to the salient features of the stimulus hindered performance across
tasks.
The most striking and pervasive aspect of the neuropsychological evaluation, however,
was the degree of stuck-in-set perseveration shown. This is particularly well illustrated by the
patient's persistence in bisecting lines on the Trailmaking Test (see Fig. 1). Line bisection had
been the appropriate response for the Cancellation Test administered earlier. Stuck-in-set
perseveration was also demonstrated on Digit Span Backwards, when the patient persisted
in repeating the numbers in the presented order, as in the previous task. Other examples
included: failure to alternate the production of cursive 'm's and 'n's; failure to switch from
addition to subtraction: and failure to point to a series of objects in order, pointing instead to
each object on every trial. There were very few instances of recurrent or continuous
perseveration in this evaluation.
Continuous perset'eration
W.S. is a 69-yr-oid right-handed male admitted for evaluation of dementia secondary to
Parkinson's disease. Tremor of right upper and lower extremeties first led to diagnosis 18
months prior to admission. Treatment course has been notable for sensitivity to antiParkinsonian medications, manifested by hallucinations and paranoia. Medical history is
remarkable for Paget's disease and for an automobile accident at age 29 with possible 24-hr
loss of consciousness.
Attention was variable throughout the neuropsychological evaluation. Performance on
visuospatial tasks was extremely slow and segmented. Pull to small details occasionally
VARIETIES OF PERSEVERATION
729
x/x,/
(A)
(B)
End
@
@
@
@
CO)
FIG. I. Examples of stuck-in-set perseveration. (A) Performance on a task of line bisection; (B)
carryover of line bisection to a task of connecting numbered dots; (C) line bisection observed on
subsequent task of alternately connecting numbered and circled dots.
730
resulted in loss of set on constructional tasks. Performance was also poor on verbal tasks
requiring abstraction or manipulation of knowledge. Spontaneous generation of words to
categories was limited. Recall of verbal passages, however, was adequate.
The most notable aspect of this evaluation was the presence of continuous perseveration.
This is best exemplified in his production of multiple loops but is also observed in drawings to
command (see Fig. 2) and the Rey-Osterrieth Complex Figure. Recurrent and stuck-in-set
perseveration were only rarely evident.
Recurrent perscveration in the non-verbal modality is well demonstrated by J.S., a 51-yrold left-handed former accountant. Five years prior to admission this patient first developed
VARIETIESOF PERSEVERATION
731
Table 6. Recurrent perseveration on the vocabulary subtest of the WAIS-R in patient H.Z.
Word to be defined
Definition
Bed
Ship
lay on
lay on, no ship, bed
Winter
Breakfast
signs of lethargy, right-sided weakness and mutism. Neurologic evaluation revealed a left
fronto-parieta~ infarction. Past medical history is significant for spinal surgery to alleviate
chronic neck, back and leg pain. The current admission was precipitated by pain in the right
arm and leg.
Residual expressive difficulties made verbal testing difficult. Preserved abstraction ability,
however, was demonstrated on the similarities subtest of the W A I S . Visuospatiai capacities
were mildly to moderately impaired. There was p o o r attention to detail on the picture
completion and picture arrangement subtests. Constructions were generally simplified.
Calculations were marked by c o m p u t a t i o n a l errors. M e m o r y was p o o r on tasks involving
constructions but s h o r t - t e r m recognition was within n o r m a l limits. There was little
incidental learning.
Recurrent perseveration was exhibited on stick design construction (see Fig. 3A), drawings
to c o m m a n d (see Fig. 3B) and the Benton Visual Retention Test. T h e pattern of responses on
the Raven Test of Progressive Matrices was also suggestive of recurrent perseveration, as was
performance on the Wisconsin C a r d Sorting Test.
Model
Memory
T
A
FIG. 3. Examples of recurrent perseveration in the non-verbal modality. (A) Performance on a task of
reproducing stick designs; (B) patient's drawing of a clock with recurrence of the number 7.
Acknowled#ement--We thank Drs Edith Kaplan, Hiram Brownell and Loraine Obler, and Ms Marjorie Nicholas
for advice on the development of this paper. This project is supported by funds from the Veterans Administration
Medical Research Service.
732
1. ALLISON,R. Perseveration as a sign of diffuse and focal brain damage---II. Brit. Meal. J., 2, 1095-1101, 1966.
2. ALLISON,R. and HURWITZ, L. On perseveration in aphasics. Brain 90, 429-448, 1967.
3. ALTMAN,J., BRUNNER,R. and BAYER,S. The hippocampus and behavioral maturation. Behar. Biol. 8, 557-596,
1973.
4. BOUC~R, J. Alternation and sequencing behavior, and response to novelty in autistic children. J. Child
Psychol. Psychiat. 18,67--9:2,-19"17."
5. BUCK1NG~M,H., WmTAKER,H. and WmT^KER, H. Alliteration and assonance in neologistic jargon aphasia.
Cortex 14, 365-380, 1978.
6. BUCKINGHAM,H., WHITAKER,H. and WHITAKER,H. On linguistic perseveration. In Studies in Neurolinyuistics,
WHITAKER, H. and WmTAKER, H. (Editors), Vol. 4. Academic Press, New York, 1981.
7. BUTTER,C. Perseveration in extinction and in discrimination reversal tasks following selective frontal ablations
in Macaca mulatta. Physiol. Behav. 4, 168-171, 1969.
8. DRACHMAN,D. and L~vrrr, J. Human memory and the cholinergic system. Archs Neurol. 30, 113-121, 1974.
9. FREW~N, T. and GATHERCOLE,C. Perseveration---the clinical symptoms---in chronic schizophrenia and
organic dementia. Br. J. Psychiat. 112, 27-32, 1966.
10. FULD,P., KATZMAN,R., DAVIES,P. and TERRY,R. Intrusions as a sign of Alzheimer's dementia: chemical and
pathological verification. Ann. Neurol. 11, 155-159, 1982.
11. GMU~Tr, M. Levels of processing in sentence production. In Language Production, BU~RWORTH, B.
(Editor), Vol. 1, pp. 177-220. Academic Press, London, 1980.
12. GOLDMAN, P. Functional development of the prefontai cortex in early life and the problem of neuronal
plasticity. Exp. Neurol. 32, 366-387, 1971.
13. GOLDMA~q,P., ROSVOLD, H. and M|SHKIN, M. Evidence for behavioral impairment following prefrontal
Iobectomy in the infant monkey. J. comp. physiol. Psychol. 70, 454-463, 1970.
14. GOLDST~n~,K. Language and Language Disturbances, pp. 16-18. Grune and Stratton, New York, 1948.
15. HALPERN,H. Effect of stimulus variables on verbal perseveration of dysphasic subjects. Percept. Motor Skills
20, 421-429, 1965.
16. FI~~N, H. and ALBERT, M. Human Neuropsychology. Wiley, New York, 1978.
17. HELMICK,J. and BERG, C. Perseveration in brain-injured adults. J. Commun. Dis. 9, 571-582, 1976.
18. Hut)sou, J. Perseveration. Brain 91, 571-582, 1969.
19. K~NSnOURNLM. and WARRINGTON,E. A study of visual perseveration. J. NeuroL Neurosurg. Psychiat. 26,
468-475, 1963.
20. Lr~s, A. and SMITH,E. Cognitive deficits in the early stages of Parkinson's disease. Brain 106, 257-270, 1983.
21. LEICESTER,J., SIDMAN,M., STODDARD,L. and MOHR, J. The nature of aphasic responses. Neuropsvchologia 9,
141-155, 1971.
22. LIEPMANN,H. Ueber storungen des handlens bei gehirnkranken. Karger, Berlin, 1905.
23. LURIA,A. Two kinds of motor perseveration in massive injury of the frontal lobes. Brain 88, 1-10, 1965.
24. MATEER,C. Impairments of nonverbal oral movements after left hemisphere damage: a foliowup analysis of
errors. Brain Lang. 6, 334-341, 1978.
25. MEADOWS,J. and MUNRO, S. Palinopsia. J. Neurol. Neurosurg. Psychiat. 40, 5-8, 1977.
26. MILNER, B. S~m~ effects ~f fr~nta~ ~b~t~my in man. In The Fr~nta~ Granu~ar C~rtex and Behavi~r` WARREN`J.
and AKERT, K. (Editors), pp. 313-334. McGraw-Hill, New York, 1964.
27. MILNER,B. Interhemispheric differences in the localization of psychological processes. Br, reed. J. 27, 272-277,
1971.
28. MISHKI~q,M. Perseveration of central sets after frontal lesions in monkeys. In The Frontal Granular Cortex and
Beharior, WARREN,J. and AKERT, K. (Editors), pp. 219-241. McGraw-Hill, New York, 1964.
29. NEIss~, A. Krankenvorstellung (Fall yon "'Asymobolie"). All0. Z. Psychiat. 51, 1016-1021, 1895.
30. OSCAR-BERMAN.M., HEYMAN,G., BONNER, R. and RYDER, J. Human neuropsychology: some differences
between Korsakoff and normal operant performance. Psychol. Res. 41,235-247, 1980.
31. PETRIDES,M. and MILNER,B. Deficits on subject ordered tasks after frontal and temporal lobe lesions in man.
Neuropsycholo,qia 20, 249-262, 1982.
32. RosE, D. Some functional correlates of the maturation of neural systems. In Biological Studies of Mental
Processes, CAPLAN, D. (Editor), pp. 27-43. MIT Press. Boston, MA, 1980.
33. SAYLES,D. Cortical excitability, perseveration, and stuttering. J. Speech Hear. Res. 14, 462-475, 1971.
34. SmNDLER, A., HIER, D. and CAPLA~q,L. Intrusions and perseverations. Paper presented at the American
Academy of Neurology Meeting, 29 April, 1983.
35. SIEGEL,A., HARROW, M., REXLLY,F. and TUCKER,C. Loose associations and disordered speech patterns in
chronic schizophrenia. J. herr. ment. Dis. 162, 105-112, 1976.
36. SWASH,M. Visual perseveration in temporal lobe epilepsy. J. Neurol. Neurosurg. Psychiat. 42, 569-571, 1979.
37. WEPMAN,J. Aphasia therapy: a new look. J. Speech Hear. Dis. 37, 203-214, 1972.
38. YAMADORLA. Verbal perseveration in aphasia. Neuropsychologia 19, 591-594, 1981.