Neumimycltology Review, Vol. 9, No. 1,1999

Russian Neuropsychology After Luria

Janna M. Glozman1-2

It is now more than 20 years after Luria's death in 1977. His collaborators, disciples, and follow-ers both in Russia and abroad continue to further develop his work. The development of Russianneuropsychology reflects the universal tendency to replace static neuropsychology, which relatesindividuals' behavior to fixed cerebral lesions, with dynamic neuropsychology, which analyzes thedynamics of brain-behavior interaction. Three types of Russian studies illustrate the latter approach:(I) neuropsychological follow-up of different nosological groups of patients in the process of medicalor psychological treatment, (2) studies of cognitive evolution (developmental neuropsychology), and(3) studies of cognitive involution (neurogeriatrics). All studies focus on cortico-subcortical and inter-hemispheric relationships. Another change in modern Russian neuropsychology consists of combiningthe qualitative approach with the quantitative one, but the system of rating is based, following Luria'stradition, on the psychological evaluation of each task's structure and the qualitative analysis of thepatients' performance and possibilities for its correction. Hence, Luria's creative and comprehensiveapproach stimulates the further development of neuropsychology in Russia.

KEY WORDS: Neuropsychological development; interhemispheric interactions; Parkinsonism: neuropsychol-ogy of memory; neurolinguistics: cerebrovascular neuropsychology; developmental neuropsychology; neuropsy-chology of older persons; rehabilitation.

GENERAL TRENDS IN THE DEVELOPMENT OFNEUROPSYCHOLOGY

It is now more than 20 years after Alexander R.Luria's death in 1977. His collaborators, disciples, andfollowers both in Russia and abroad continue to develophis work. The development of Russian neuropsychologyreflects the universal tendency to replace static neuropsy-chology, which relates individuals' behavior to fixed cere-bral lesions, with dynamic neuropsychology, which ana-lyzes the dynamics of brain-behavior interaction (Rourke,1982; Tupper and Cicerone, 1990). The ability of neu-ropsychology to adapt to changes in techniques, ideas, andpatients served accomplishes its potential to be of serviceto humanity (Horton and Puente, 1986).

1 Psychology Department, Moscow Stale University, Moscow, Russia.- All correspondence should be directed to the author at Psychology

Department, Moscow State University, 8 Mohovaya St., b.5, Moscow103009, Russia.

I would like to propose the following model of devel-opment in neuropsychology, which comprises three over-lapping and coexisting phases (Fig. 1).

FIRST PHASE OF NEUROPSYCHOLOGYDEVELOPMENT

In the first phase, the emphasis for neuropsycholo-gists was on the brain and its relationship to different be-haviors. The neuropsychology of this period was consid-ered by Luria to be a "field of practical medicine" (Luria,1973, p. 17). Similar understanding characterizes the bookof the French neuropsychologist H. Hecaen, Introductiona la neuropsychologie (1972). The main and most valuableattainment of this phase is a revision by Luria of the con-cepts of localizationism and antilocalizationism and thecreation of the theory of the dynamic and systemic cere-bral organization of mental processes. The creation of thistheory resulted in functional analysis of different brainsystems and description of frontal, parietal, temporal, andother syndromes.

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33

Glozman34

Fig. 1. Model of development in neuropsychology.

Recent development of the functional systems ap-proach follows two main lines: (1) a study of intrahemi-spheric specialization (asymmetry) and interhemisphericinteractions and (2) research into subcortical brainpathology.

The Problem of Interhemispheric Interaction

Study of interhemispheric interaction was startedduring Luria's life by E. G. Simernitskaya, L. I.Moskovichyute, and N. K. Korsakova. Interhemisphericspecialization for different forms of memory was demon-strated in research (Korsakova et al., 1979; Simernitskaya,1978), as was the greater vulnerability of the right hemi-sphere to cerebral pathology (Korsakova et al., 1978). Theright hemisphere was found to be slower in informationprocessing than the left hemisphere (Krotkova et al., 1982)and less able to regulate and accelerate one's mental ac-tivity (Enikolopova, 1998; Homskaya, 1995).

An important contribution was made by researchersfrom Leningrad (now St. Petersburg) including Vadim L.Deglin, Yakov A. Meerson, Ludvig I. Wasserman, N. N.Nikolaenko, O. P. Trachenko, Alexandre G. Zalzman, andothers. It was shown, for instance, that each hemisphereis specific for different types of reasoning, such as em-pirical or logical reasoning, and that there are unilater-ally and bilaterally realized perceptive and verbal func-tions, or a "competence" of each hemisphere (Meerson andDobrovolskaya, 1998; Nikolaenko et al., 1997; Zalzman,1989). The right hemisphere can analyze the perceptivefeatures of every stimulus, but not its semiotic (phoneticand semantic) characteristics. Conversely, the left hemi-sphere is able to analyze categorical, phonetic, and seman-

tic characteristics of images and partly its perceptive fea-tures (Meerson and Zalzman, 1989). Each mental activityis realized through the interaction of both hemispheres,each making a specific contribution. Recent studies byHomskaya and Batova (1998) have also shown interhemi-spheric differences in positive or negative character as wellas in intensity and stability of human emotions. New stud-ies show that interhemispheric differences can be revealedon both the cortical and the subcortical levels. Cognitivedefects specific for the left hemisphere are more evidentwith cortical lesions, whereas subdominant syndromes ap-pear predominantly after subcortical lesions of the righthemisphere (Moskovichyute, 1998).

With this, there is a special cerebral mechanism ofinterhemispheric interaction, ensured by the corpus callo-sum. Experimental study of its role in cognitive activitywas carried out by Lena Moskovichyute, one of Luria'sbrightest disciples who now lives and works in Boston atthe VA Medical Center. Modality-specific (only visual ortactile or acoustic) disturbances of interhemispheric inter-action and the dyscopia-dysgraphia syndrome (ability towrite only with the right hand and draw only with the leftone) after partial dissection of the corpus callosum havebeen described. It has been shown that the syndrome of thebisected brain might be revealed only after dissection ofposterior regions of the corpus callosum (Moskovichyute,Simernitskaya, et al., 1982).

The dynamic processes of different mental functionsafter treatment depend on injury lateralization (Glozmanet al., 1991; Korsakova el al., 1978; Vasserman and Lassan,1989; Vasserman and Tets, 1981). It was revealed that thedisturbances were more pronounced after left-hemispherelesions, but their regression was quicker and more thor-ough than that in patients with right-hemisphere damage.

Russian Neuropsychology After Luria 35

Meerson (1989) thinks that the "greater compensating ca-pabilities of the left hemisphere are due to its particularfeatures such as abundance in neural connections, closerelationships with deep structures, greater mobility andstrength of nervous processes. All this contributes to theformation of many flexible probabilistic relationships andit assures a plasticity and a replaceability of some struc-tures" (p. 37). In other recent studies, it has been foundthat a transformation of interhemispheric interaction canfavor the rehabilitation process (Krotkova, 1998).

Neuropsychology of Parkinsonism

Research into subcortical behavioral pathology afterthalamic, midbrain, or basal ganglia dysfunction or othersubcortical lesions was carried out by Luria (1973) fromthe viewpoint of three main functional units of the brain,which are discussed in moredetail later in this article. Sub-cortical regions maintain and regulate an optimal level ofcortical tone necessary for organized, goal-directed ac-tivity. A good model for studying cognitive disturbancesdue to subcortical damage is Parkinson's disease (PD).Study of PD was begun at Burdenko Neurosurgical In-stitute by Korsakova and Moskovichyute (1985) and thencontinued by me and my colleagues at the Moscow Med-ical Academy. Six spheres of mental activity (patient'sgeneral characteristics, praxis, gnosis, language, mem-ory, intelligence) were assessed in more than 150 patientsby using Luria's battery and including both the qualita-tive and quantitative evaluation of the defects (Glozmanet at., 1996). The scoring system took into considerationthe primacy-nonprimacy of defects and the possibilitiesof their correction, and utilized normative data (Glozmanet at., 1991; see also, other Glozman article in this issue).In addition, special attention was attached to the neurody-nainic features of cognitive activity, which are considered

crucial for the PD pattern (Korsakova and Moskovichyute,1985; Pillon et al., 1989). We measured the time of ful-fillment of some motor, mnestic, and intellectual tests(symptoms of bradykinesia, bradymnesia, and bradyphre-nia), general brain activity of patients, and patients' verbalactivity in controlled and uncontrolled association tests.The patients were also assessed using Wechsler Adult In-telligence Scale (WAIS) and Mini-Mental State (MMS)methods and with a special standardized inventory of so-cial adaptation (Glozman, 1991).

Significant difference in the degree and pattern ofcognitive disturbance was revealed between the group ofpatients without cerebral atrophy or with mild cerebral at-rophy and a group of patients with pronounced cerebral at-rophy. Most of those patients (65%) of the latter group metthe criteria for dementia described in Diagnostic and Sta-tistical Manual of Mental Disorders, 3rd edition, revised(DSM-IH-R) and had a high degree of social disintegra-tion. These patients had pronounced cognitive disordersin almost all mental spheres. Our recent studies also revealdifferent patterns of cognitive disturbance in patients withexternal and internal cerebral atrophy.

We can therefore represent the role of such factorsas aging, PD, and cerebral atrophy in the pathogenesisof cognitive disorders. Nevertheless, PD should not beconsidered as accelerated aging. The pattern of cognitivedisturbances in older persons with PD is a specific com-bination of "natural" brain alterations appearing with ageand specific impairments caused by the disease. The pat-tern is not the sum of both components, but a qualitativelynew complex of symptoms.

The analysis of the factors influencing the develop-ment of cerebral atrophy has revealed that cerebral atro-phy is significantly more frequent for persons older than60 years and for patients having more pronounced neuro-logical symptoms. Although the duration of PD does notcontribute to the development of cerebral atrophy, the age

Table I. Specific Disturbances of Mental Functions in Different Forms of Parkinson's Disease(Mean ± Standard Deviation)

Forms of PD

Disturbances of

1. Praxis2. Gnosis3. Memory4. Speech5. IntellectSummarized score of mental

Tremorous(n=18)

0.3 ±0.1 7O.I4±0.160.98 ±0.770.22 ±0.250.16±0.13

15.45 ±10.45

Akinelic-rigid(n=26)

0.64 ±0.280.40 ±0.211. 93 ±1.020.55 ±0.47!. 07 ±1.03

38.61 ±20.06

Significance ofDifferences

<O.OI<0.05<0.05

n/s<0.05<O.OI

functions disturbances

36 Glozman

Table 11. Relationship Among Differenl Methods of Assessment (Mean ± Standard Deviation)

Lurian assessment (summarized ratings)Mini-Mental State (MMS) exam scoresWechsler Adult Intelligence Scale — Revised

(WA1S-R) IQ scores

0-2528.9 ±2.0119±9

26-5527.3 ±2.0I 0 7 ± l l

>5524.093±6

of onset of the disease is essential. Cerebral atrophy de-velops much more quickly if the onset of PD occurs at alater age.

Cognitive disturbances were more pronounced in theakinetic-rigid form of PD than in the tremorous form(Table 1). The evidence from our Lurian assessmentscorrelated well with that from psychometric methods: Thehigher the summarized Lurian ratings of disturbances, thelower were the patient's achievements on Wechsler testingand in MMS exams (Table 2).

It is possible to interpret the data from our investiga-tions using Luria's conceptualization of three functionalunits of the brain: the activational, the information pro-cessing and storage, and the control units (Luria, 1973).Russian studies have revealed that the activational com-ponent of cognitive processes was impaired in all patientswith PD. Severe disorders of cognitive functions (praxis,gnosis, speech, memory, intelligence) related to the secondfunctional unit of the brain were observed predominantlyin older patients with PD and cerebral atrophy. Executivebehavior defects related to the control and regulation ofcognitive functions occurred in patients with a long dura-tion of PD (exceeding 5 years). Therefore, the involvementof the first functional unit of the brain is the earliest andmost universally impaired, whereas the other two func-tional units are disturbed during specific conditions of theevolution of PD.

Dementia should not be considered as an obligatorycomponent of PD; it is consequential to involvement ofall three brain functional units and provokes social dis-integration of the patients. It should also be pointed outthat dementia in patients with PD and cerebral atrophy,unlike that in patients without cerebral atrophy, is not lim-ited to the symptoms of so-called subcortical dementia(such as slowing and exhaustibility of mental activity).It includes some cortical cognitive disorders, the patternof which is different from that of the cortical cognitivedisorders of Alzheimer's disease (AD). A detailed com-parison of neuropsychological evidence in PD, AD, andvascular pathology is now under study. Only one feature ismentioned here: that of voluntary-regulation impairmentin patients with AD, illustrated by their drawings on com-mand and by copying (Fig. 2). Conversely, in patients withPD (especially in those without severe atrophy), cortical

Fig. 2. Examples of voluntary-regulation disorders in older patients.

stimulation and regulation can often compensate for thedefects of subcortical activation.

This information has allowed us to work out a pro-gram of rehabilitation of motor subcortical disturbancesin PD that helps realize Luria's idea of the cortical (vi-sual) mediation of movements, that is, with use of ex-ternalized compensations that are consequently internal-ized (Glozman, 1996a). Preliminary results reveal not onlythe efficiency of the program for stable regression of spe-cific movement problems, but also its generalized effect onbradykinesia, bradyphrenia, and general corticalactivity.

A specific problem of Parkinsonism is depression.To reveal specific manifestations of depression inParkinsonism, we looked at the psychological structure ofdepression using the model shown in Fig. 3. Thisallowed us to find objective criteria of the severity ofdepression in Parkinsonism. It was revealed that a

Russian Neuropsychology After Luria 37

Fig. 3. The psychological structure of depression.

premorbid predisposition to depression is crucial for iden-tifying the degree of depression severity after the onset ofParkinsonism, and for patients, also the potential benefitfrom pharmacotherapy.

SECOND PHASE OF NEUROPSYCHOLOGYDEVELOPMENT

Returning to the proposed model of development inneuropsychology (see Fig. 1), in the second phase thestructure of mental activity or higher mental functionshas been the focus of attention and secondarily the lo-calization of such processes in the brain. Such study gavebirth to different syndromes of mental disturbances: localor regional disturbances, resulting in research on the neu-ropsychology of memory (Luria, 1976b), neurolinguistics(Luria, 1976a), and so on; diffuse syndromes after cere-brovascular pathology; syndromes of underdevelopmentor atypical development, studied by developmental neu-ropsychology; and last, mental dysfunctions in healthysubjects in specific functional states or with some indi-vidual particularities or accentuations in cognitive perfor-mances. This last line of investigation gave birth to studyof the neuropsychology of individual differences. The re-cent development of each of these lines of investigation isdescribed briefly next.

Neuropsychology of Memory

The actual studies of memory disorders, and theirstructure and underlying mechanisms, are mainly approa-ched with respect to interhemispheric interaction in mnes-tic activity (Korsakova and Mikadze, 1982; Korsakovaet al., 1979; Simernitskaya, 1978). It has been found thatthe right hemisphere assumes more elementary, involun-tary, and automatized forms of mnestic activity, whereasthe left hemisphere is responsible for complex, voluntaryforms of memorizing (Simernitskaya, 1978). Further, ithas been revealed that the right hemisphere takes part in thefirst stage of immediate memorizing, then the left hemi-sphere participates in delayed recall (Korsakova et al.,\ 979). Coding and reproduction of verbal information arebased on linguistic characteristics, mediated by the func-

tions of the left hemisphere, whereas visual information ismainly coded on perceptive characteristics, and its memo-rizing and reproduction are effectuated predominantly bythe right hemisphere. Recognition processing is less spec-ified than is recall and can be relatively preserved in manytypes of local brain damage. Hence, "information process-ing can be effectuated through several parallel channels,each operating with different characteristics. Included ineach channel during information processing is informa-tion that depends upon the level of organization of thematerial" (Korsakova and Mikadze, 1982, p. 109).

Our last studies of memory disorders in patients withPD revealed hemispherically specific types of mistakes:For example, a lesion in the dominant hemisphere in-creased retroactive inhibition, whereas one in the non-dominant hemisphere influenced more proactive inhibi-tion. The left hemisphere is predominantly responsible foractivity and selectivity of memorizing, and the right oneensures retention of item order and plasticity or flexibilityof memorizing.

Neurolinguistics

Neurolinguistics has had intensive development afterLuria at the Laboratory of Neuropsychology of MoscowMedical Academy, directed by L. S. Tsvetkova. Studiesof lexical-semantic disorders in aphasia by T. V. Akhutinaand me provided new knowledge about language mecha-nisms, the organization of grammar and of the inner lex-icon in normal subjects and in subjects with pathology(Akhutina, 1981; Akhutina and Glozman, 1995;GIozman,1978). One example of recent developments in neurolin-guistics in Russia is a comparative study to assess vo-cabulary in cortical and subcortical pathology (Glozman,1996b). For the purposes of this investigation, we workedout an analysis of data from the controlled and uncon-trolled word association test, which includes both the pro-cess of recall and the structure of the vocabulary wordsreceived.

Dynamic features of the associative process includeboth agility and motility (ability to shift). The first is mea-sured by the average output, the second through a non-productive recall index. The next step in our analysis isa detailed study of the subject's verbal production. It canreveal first the structure of lexicon, that is, its differentparts—the kernel, peripheral, or individualistic features—and then the psycholinguistic features that determine therelation of a given word to a specific part of lexicon.

Our research group analyzed 140 sets of words, whichamounted to 1,381 items of vocabulary, in four age- andeducation-matched groups of subjects: healthy subjects,

38 Glozman

patients with PD, and patients with motor and sensoryforms of aphasia. It was found first that cortically basedbrain damage, provoking aphasia, decreases verbal activ-ity more than a subcortical lesion in patients with PD does.The verbal output was below the lower limit of normalvariation in 76% of patients with aphasia and in 35% ofpatients with PD. A decrease of verbal activity correlatedwith the severity of cognitive disturbances in PD and withaphasia severity. An increase of verbal activity was a goodindicator of rehabilitation of the patient with aphasia andwas a good means to evaluate the effect of reeducation ofpatients with aphasia.

Given these results, no significant differences werenoted between patients with motor aphasia and patientswith sensory aphasia for generation of both nouns andverbs. This finding throws into question the usefulness ofthe fluency factor as a main dimension for subdivisionamong aphasic syndromes. The differences between themwere revealed, instead, through a qualitative analysis of theprocess of recall, particularly in preferential use of a syn-tagmatic or paradigmatic strategy of generation of words.This evidence correlates well with Luria-Jakobson's ap-proach to aphasia, which differentiates two main types of

aphasic disturbances, those due to a lesion of posteriorregions of the brain and those due to a lesion of ante-rior regions of the brain, with a predominant impairmentin paradigmatic or syntagmatic relations in grammar aswell as in vocabulary (Akhutina, 1981; Glozman, 1978;Goodglass, 1993; Jakobson, 1956; Luria, 1976a).

In addition, the number of nonproductive items wasparticularly high in the group with sensory aphasia. Typesof errors were also different: perseverations in the groupwith motor aphasia and word combinations in the groupwith sensory aphasia. The semantization index, reflectingthe tendency to group the named words into meaningfullyrelated groups, was significantly decreased in all patientswith brain damage, compared with the index of healthysubjects. The number of words in each semantic groupwas restricted. This may suggest a narrowness of vocab-ulary, predominantly its verbal part, through both corticaland subcortical brain damage. Further, both healthy sub-jects and patients with aphasia preferred to produce wordswithin a restricted category, whereas patients with PD of-ten resorted to a situational description. Such an unusualfinding could be explained by categorization difficultiesthat often occur in PD (Huber and Cummings, 1992).

Fig. 4. The transformation of the lexicon after cortical (aphasia) and subcortical (Parkinsonism) brain damage.

Russian Neuropsychology After Luria 39

Regarding the structure of lexicon, our research groupfound that both cortical brain damage and subcortical braindamage change little the structure of the nominal part oflexicon, but they transform significantly the structure ofverbs in both groups with aphasia. The transformationmanifests in deindividualization of the lexicon, that is, inrestriction of the individual part and expansion of periph-eral and kernel lexicon. The degree of lexicon transfor-mation is significantly more pronounced in aphasia thanin PD (Fig. 4). In both motor and sensory aphasias, theindividual parts of verbs totally disappear in patients withseverely disturbed fluency.

Psycholinguistic analysis reveals that the frequencyand the time of appearance of words in childhood are themain criteria to form the kernel part of lexicon. Further, atypical characteristic of verbal production in healthy sub-jects is a personal reflection in the named words, whichare some words from the professional vocabulary or wordsrelated to scholarship for students, and so on. In contrastto healthy subjects, all groups of patients showed a signifi-cant decrease in this feature. This defect is a key symptomof a deep transformation of vocabulary through brain dam-age, with a relatively preserved kernel part of lexicon buta limited individualized part, which mostly reflects one'sunique living experiences.

In conclusion, aphasic disorders of speech due to acortical lesion of the brain result in a deep transformationof the lexicon and a modification of interrelationships be-tween the internal parts of the lexicon. These character-istics are an indicator of a disturbance of both linguisticcompetence and linguistic performance in patients withaphasia. In PD, as a result of a subcortical lesion of thebrain, the internal structure of the lexicon is relativelypreserved, which means that the disturbance involves pre-dominantly the linguistic performance of the individual.Nevertheless, both cortical and subcortical brain damagecan interfere with verbal fluency.

In addition, recent studies in neurolinguistics as wellas in neuropsychology as a whole are characterized by aninterest in the problems of interhemispheric interaction.Thus, it has been shown that in bilinguals and polyglots,aphasia often appears after a lesion in the right hemi-sphere and depends on the circumstances of the second-language acquistion and use (Kotik-Fridgutet, 1998).Another model for studying interhemispheric interactioninvolves cases of aphasia in left-handers. A Russian study(Shohor-Trotskaya, 1998), for instance, showed conduc-tion and transcortical aphasias to be more noted in left-handers, whereas partial afferent-motor, efferent-motor,and acoustic-gnostic aphasias, as described by Luria, aremore common for right-handers with lesions of the lefthemisphere.

Cerebrovascular Pathology

The study of diffuse neuropsychological syndromesafter cerebrovascular pathology is due primarily to vas-cular neurosurgery (Luria et al., 1970; Moskovichyute,Serbinenko, et al., 1982). Luria's neuropsychology wasbased primarily on patients with circumscribed brain le-sions. This made impossible a direct transfer of estab-lished neuropsychological syndromes to cerebro vasculardisease, where each cerebral artery provides a blood sup-ply to many brain areas. Luria, in his book about cere-brovascular pathology (Luria et al., 1970), introduced anew approach to the analysis of brain correlates of theneuropsychological findings: (1) He showed which cog-nitive impairments might be associated with dysfunctionof medial frontal areas versus those that might be asso-ciated with basal frontal dysfunction, and so forth; (2)he described new defects that could be observed only incases of combined damaged areas; (3) he used a longi-tudinal approach and postulated—in an era without CTscans and other methods of visualization—that some de-fects were caused by infarcts in anterior cerebral artery(ACA) regions and that other lesions were reversible andassociated with temporary spasm of the vessel (temporaryischemia of its territory). In addition, he noted that differ-ent neuropsychological patterns could be associated withdifferent stages of the disease.

This background allowed Lena Moskovichyute toformulate a number of basic principles for cerebrovascularneuropsychology (unpublished, with personal authoriza-tion):

• Another approach to the concept of a lesion: thelesion as a possible combination of brain areasinvolved in the pathological process

• Another approach to brain con-elates of cogni-tive impairments: the search for reversible andirreversible deficits

• Possible longitudinal study• Analysis of all pathophysiological processes for

different stages of cerebrovascular disease

Moskovichyute also described cognitive deficits cau-sed by anatomical pathology of the ACAs and of themiddle cerebral arteries (MCAs); such pathology includesocclusion, stenosis, aneurysm, malformation, and hemo-dynamic changes distal to this lesion: spasm, steal, and soforth. Thus, an occlusion of the MCA causes pronouncedaphasias, apraxias, and agnosias. MCA spasm causes dis-tinct memory impairments, and sometimes acoustic-agnos-tic and acoustic-amnestic aphasias. MCA steal never re-sults in pronounced aphasias or amnesias, and all deficitsare usually mild or moderate in severity. An occlusion

40 Glozman

of the ACA causes pronounced aphasia, apraxia, lack ofmotivation, and a perseveration syndrome. ACA spasm re-sults in a confusional state and severe amnesia (modalitynonspecific). ACA steal causes variable and mild or mod-erate impairments, and more often a parietal dysfunctioncan be seen.

Neuropsychology of Older Persons

Another kind of diffuse neuropsychological syndromeis observed during cognitive involution, or in neurogeri-atric patients. Studies of this syndrome have been carriedout in Moscow by two groups of neuropsychogists: Onegroup, directed by N. K. Korsakova, works in psychiatricclinics, and another group, directed by me, works in neu-rological centers. The interest in geriatric problems is aresult of the fact that in the last few decades attentionaround the world has focused on the prolongation of lifeexpectancy. There is a resulting increased proportion ofolder persons in the world's population. Hence, it is nec-essary to identify criteria for normal (physiological) andabnormal aging, methods of prophylaxis and treatment,and early diagnosis and correction of cognitive distur-bances in older persons. Application of Luria's systemicapproach to problems of older persons makes it possibleto show both disturbed and preserved functions—evenin cases of diffuse cerebral pathology—and to evaluatethe patients' capabilities. Thus, from my viewpoint, asan example, preserved abilities for logical reasoning andcorrect judgment—even in cases of severe mnestic andregulatory disturbances—make the diagnosis of dementiaunjustified.

Luria's conception of three functional units of thebrain may work well in differentiating normal and ab-normal aging (Korsakova, 1996, 1998). In older personswithout pathology, the functioning of the first unit—that ofactivation—is predominantly disturbed, and this is man-ifested in general slowness, aspontaneity in all activities,increased inhibition of memorized information by inter-fering stimuli, and restriction of the volume of mental ac-tivities when different programs must be simultaneouslyretained and realized.

According to Korsakova's data, the process of invo-lution in older persons is not linear. Neurodynamic dis-turbances are more pronounced in the early years of olderage, between 50 and 65 years, which is considered "akind of involutional crisis" (Korsakova, 1996, p. 36), andthey are stabilized in the period from 65 to 75 years, withsome parameters—for instance, memory—approachingthe preinvolutional level. Consecutive positive or negative

dynamics depends upon almost successful surmountingof the crisis, by means of mastering compensation (vi-sual cues, exteriorization of the program, prolongation ofmemorizing phases, replacement of simultaneous prob-lem solving by successive problem solving with verbalregulation, and so on) and eliminating risk factors, suchas somatic or neurological diseases or drastic changes instereotyped activities. "Taking account of various meansfor surmounting deficits in mental functioning by normalelderly, one can say, that ageing is a stage of individualdevelopment, necessitating a change in strategies, volun-tary selection and use of new forms of mediating mentalactivity.... This agrees with contemporary views on invo-lution focussing both on deficite and positive aspects: for-mation of new means of self-conservation as a personalityin a general continuum of one's own space" (Korsakova,1996, p. 36).

Mental activity at this stage of ontogenetic devel-opment is directed more toward self-regulation than tocognition. In pathological atrophic states, such as AD orsenile dementia, not only these symptoms are aggravated,but defects in functioning of the two other cerebral units(that for coding/information processing and that for reg-ulatory activity) are also demonstrated. Defects of spatialanalysis are of special importance for provoking mentaldisorders in older persons (Balashova, 1998). Neverthe-less, a Lurian assessment reveals differential involvementof each of these units in the various types of dementia,with more preserved executive functions connected to thefrontal lobes in AD, compared with such functions in se-nile dementia.

A combination of psychometric and qualitative Lurianmethods of neuropsychological assessment permits neu-ropsychologists to better understand the mechanisms ofexecutive disturbances in different forms of cerebral patho-logy in older persons (Glozman, Levin, et al., 1998). Acomprehensive neuropsychological assessment finds thatimpaired performance on the Wisconsin Card Sorting Testin vascular dementia is due not only to the inability toswitch from one strategy to another (resulting in persever-ative responses), but also to global intellectual decline pos-sibly associated with widespread cerebral involvement. Inpatients with AD, the poor performance may be explainedfirst by a deficit in short-term and logical memory, andconstructional ability, which mediates the executive be-havior. In each kind of cerebral pathology, the executivedisturbances are connected to specific patterns of cogni-tive disturbances.

Analysis of experimental data using Luria's theoryof three functional brain units helps demonstrate that itis more correct to speak about cortical and subcortical

Russian Neuropsychology After Luria 41

components of dementia, which are dynamically connectedwith each other. The evolution of vascular pathology inolder persons manifests mainly in neurodynamic (subcor-tical) disturbances, and the progression of cognitive dis-turbances leading to the appearance of a vascular dementiais predominantly due to regulatory and operational deficitsconnected to cortical brain regions. A "corticalization" ofthe cognitive and executive disturbances thus occurs. Theevolution of AD is realized by the consecutive "frontaliza-tion" and "subcorticalization" of impairments, that is, bysuperimposed neurodynamic and regulatory impairmentsupon operational ones.

Developmental Neuropsychology

Another line of development in neuropsychologydeals with studies of cognitive evolution and specific dis-turbances of mental activity after brain damage in children.This work was begun during Luria's life by his discipleE. Simernitskaya. She assessed 306 children with local-ized brain damage, using an adapted Luria battery(Simernitskaya, 1982). Interhemispheric and intrahemi-spheric differentiation, typical for adults, was also re-vealed in children. Nevertheless, some symptoms, namely,aphasic disturbances, were significantly less frequent andhad a different pattern than that in adults after similar le-sions. Another difference consisted of a quick regressionor resolution of symptoms after surgery. The degree andcharacter of the participation of different cerebral regionsin cognitive functioning varies with ontogenic evolution asa result of the increasing integration of cerebral structuresduring development. According to Simernitskaya, under-developrnent of inter- and intrahemispheric connections insmall children explains the limited effect of localized le-sions and the improved potential for functional restorationin children.

The further growth of developmental neuropsychol-ogy in Russia follows two main lines: the study of individ-ual features during the development of cognitive functions(Akhutina, 1998;Mikadze, 1996,1998) and analysis of in-terhemispheric interaction and the "dysgenetic syndrome"in childhood (Semenovich et at., 1998). It has been shownthat Lurian methods are extremely sensitive to individ-ual dissociations in cognitive development, other causesof nontypical development, and learning disabilities. Thisevidence often forms a basis for the development of indi-vidual corrective education programs that use the child'spotentials to help surmount cognitive difficulties or under-development.

Neuropsychology of Individual Differences

A new line of investigation in contemporary neu-ropsychology is that of individual differences, which isan application of neuropsychological concepts and meth-ods to the assessment of healthy subjects. These stud-ies have been conducted by Homskaya and her disciplesfrom Moscow, Orenburg, and Kharkov (Homskaya, 1996;Homskaya and Batova, 1998; Homskaya et al., 1997;Moskvin and Moskvina, 1998; Privalova, 1998). Deter-mination of normal functioning is of fundamental valuefor a better understanding of pathological disturbances.A neuropsychological approach to individual differencestries to explain normal functioning by using principles ofcerebral organization, particularly characteristics of inter-hemispheric asymmetry (motor, acoustic, and visual) andinterhemispheric interaction. This approach allowed thegroup of researchers directed by Homskaya to identify 27possible profiles of lateral brain organization in normalsubjects and the correlation of these profiles to aspects ofcognitive, motor, and emotional activity of the subjects,as well as to their adaptive abilities. Each profile of in-terhemispheric organization has its own "psychologicalstatus" (Homskaya et al., 1997).

THIRD PHASE OF NEUROPSYCHOLOGYDEVELOPMENT

Neuropsychology and Real Life

The third phase of development in neuropsychology(see Fig. 1) focuses on the interrelationship between a pa-tient and his or her society or environment. This phase nec-essarily integrates neuropsychological and real life data.The neuropsychological assessment of both adults andchildren should emphasize the patient's strengths, whichare important in his or her rehabilitation program and pre-dict his or her ultimate integration into society. Programsof rehabilitation should take into account patients' socialneeds. This principle was first realized in aphasiology asthe so-called sociopsychological aspect of rehabilitation(Tsvetkova et al., 1979, 1985), and now it is embodied inwork in developmental neuropsychology.

The recent advancement of developmental neuropsy-chology deals with problems of diagnosis and prophylaxisof learning disability (Akhutina, 1998; Akhutina et al.,1996; Mikadze, 1996). Early diagnosis of abilities andreadiness for school, as well as timely correction of learn-ing difficulties at preschool or elementary grades, can

42 Glozman

prevent stable learning disabilities. Neuropsychologicaldiagnosis of causes responsible for learning problems isbased on three main concepts: (1) heterogeneity in thematuration of brain structures and connections in the de-velopment of functional systems, (2) a correspondence be-tween the child's abilities and exigencies of the learningprograms, and (3) the fact that a Lurian neuropsycholog-ical assessment can identify the cerebral zones involvedin various functional systems and reveal correspondingweaknesses (Akhutina, 1998; Mikadze, 1996, 1998).

Different adaptations of Luria's battery are now usedfor qualitative and quantitative (standardized) neuropsy-chological assessment of children at preschool and schoolages. The emphasis of these assessments is a modificationfrom diagnostic evaluation to prognostic and correctivesuggestions; that is, the main task is to suggest correctivestrategies for the child. Luria's approach provides greatscope for accomplishing this task together with investigat-ing the process of functional system maturation (Akhutinaet al., 1996).

Neuropsychological assessment of children withLuria's battery is now combined with a new method of"tracking diagnosis" (Pylaeva, 1998), or systematic ob-servation of a child at lessons or at play by the neuropsy-chologist. This method reveals neurodynamic features ofthe child's activity as well as his or her zone of proxi-mal development, using Vygotsky's theory, which makesit possible to develop and carry out an individualized pro-gram of correction. Akhutina and Pylaeva worked out sev-eral methods of developing the functions of control andprogramming in 5- to 7-year-old children, based on thisprinciple of proximal development. Thus, in common ac-tions, an adult first realizes these disturbed functions for achild, transferring them gradually to the child. The transferis effected through externalized means and by a visualizedsiep-by-step program of actions that is consequently in-ternalized and compressed by the child.

The next problem is that of the qualitative and quan-titative evaluation of the outcome of rehabilitation effortsand the degree of a patient's ultimate integration into so-ciety. A multiscale inventory was developed to evaluatepatients' social readjustment at the three main levels of apatient's work-related, family-related, and day-to-day ac-tivity (Glozman, 1991). This inventory was successfullyused in follow-up of neurosurgical and Parkinsonian pa-tients. A new inventory is now being developed, and it isbeing designed to evaluate the level of social adaptationor disintegration, including that of caregivers (Glozman,Bicheva, et al., 1998). It is the first step to a neuropsycho-logical understanding of the family (not counting a studyof interfamily relationships of patients with aphasia thatwas part of a more general exploration of interrelations

between communication disorders and personality in dif-ferent nosological groups; Glozman, 1987/in press).

CONCLUSION

This brief review provided some insight into the va-riety and abundance of neuropsychological studies in thepost-Luria period. In summary, three main trends can beseen in the development of Russian neuropsychology afterLuria:

1. Extensive further expansion of research and prac-tice, that is, embracing numerous new domains andnosological patient groups

2. Combination of qualitative and quantitative approaches3. A social and personality-based orientation

All the aforesaid proves that Luria's creative and compre-hensive approach stimulates the further development ofneuropsychology in Russia and throughout the world.

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