Neurological literature: Hyperkinetic motor perseverations

Posted in Neurological Literature on 8th Dec 2017

 

AJ Larner, Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, L9 7LJ, UK.
Correspondence to: a.larner@ thewaltoncentre.nhs.uk
To cite: Larner AJ. ACNR 2017;17(2):16.
Published online: 11/12/2017

 


Alexander Romanovich Luria (1902-1977) was one of the most celebrated neuropsychologists of the 20th century, noted perhaps particularly for his work on frontal lobe functions. Reading a volume dedicated to his legacy,1 I was struck by a chapter describing the Executive Control Battery (ECB), developed by Luria’s pupil Elkohonon Goldberg and based on Luria’s studies.2 Although not familiar to me as such, clearly the ECB has influenced other tests of executive function, such as the much briefer Frontal Assessment Battery (FAB)3 (this has been used in some of the clinical work undertaken in Liverpool, either as the main focus of interest4,5 or as comparator6).

ECB consists of four subtests, of which the first is the Graphical Sequences Test. This was designed to elicit perseverations, of which four types are described. The first of these, hyperkinetic perseveration, is described thus:

Hyperkinetic perseveration … is defined as an inability to stop a single elementary grapho-motor component such as drawing a circle or straight line. … Here the patient literally continues to draw a circle or straight line over and over.7

This account put me in mind of a possible literary example of this phenomenon, a character drawing repeated circles encountered in Joseph Conrad’s 1907 novel The Secret Agent.8 (Spoiler alert: if you have read this far and plan to read further, what follows discloses some of the key plot features of Conrad’s novel.)

Adolphe Verloc, the titular “secret agent”, lives in Soho with his wife, Winnie, her mother, and her brother, Stevie. The latter is “a terrible encumbrance”, “delicate and, in a frail way, good-looking too, except for the vacant droop of his lower lip” (ref. 8, p. 7). Although he has apparently learned to read and write he is not able to sustain work, for example as an errand boy, although he “helped his sister with blind love and docility in her household duties” (9). Indeed his most frequent descriptor is docile or docility (47,126,136,182), but “In the face of anything which affected … his morbid dread of pain, Stevie ended by turning vicious” (134). His future is a source of concern to his mother and sister. Evidently he has a limited verbal output, but feels deeply for the sufferings of poor people and animals. In addition:

His spare time he occupied by drawing circles with compass and pencil on a piece of paper. He applied himself to that pastime with great industry, … (9)

At a meeting of Verloc’s small circle of anarchists, they notice:

… the innocent Stevie, seated very good and quiet at a deal table, drawing circles, circles, circles; innumerable circles, concentric, eccentric; a coruscating whirl of circles that by their tangled multitude of repeated curves, uniformity of form, and confusion of intersecting lines suggested a rendering of cosmic chaos, … (36)

Later, however, Stevie’s behaviour changes:

… when discovered in solitude [Stevie] would be scowling at the wall, with the sheet of paper and the pencil given him for drawing circles lying blank and idle on the kitchen table. (148)

This change is a marker of (or metaphor for?) Verloc’s increasing influence over Stevie, culminating in his inducing (radicalising?) his brother-in-law to perpetrate a bombing in Greenwich Park, notionally on behalf of the anarchists. This goes wrong, the bomb explodes before being left, and Stevie is blown to pieces.

The “idiot character as gullible bomber” is picked up on in Patrick McDonagh’s cultural history of idiocy (ref. 9, especially at pp. 310-8), which examines the “symbolic work of idiocy in this discourse” (23). McDonagh suggests that Stevie’s “mystical circles replace language” (317) and that “the novel’s conflicting ideological positions lie … in the eternal chaos of Stevie’s circles” (318). The novel itself was based on an 1894 incident, similar in many respects, including the assertion that the bomber was an “idiot”.

Is any medical explanation of Stevie forthcoming? From within the text itself, we have this opinion from Comrade Alexander Ossipon, “- nicknamed The Doctor, ex-medical student without a degree”, who lectures to working-men’s associations on the “socialistic aspects of hygiene” (ref. 8, p. 37), i.e. eugenics (ref. 9, p. 315). Observing Stevie drawing his circles in the kitchen, Ossipon opines that he is “typical of this form of degeneracy”, and that “It’s enough to glance at the lobes of the ears. If you read Lombroso – ” (ref. 8, p. 37). Another anarchist, Karl Yundt, then promptly rubbishes the views of Lombroso.

With the benefit of hindsight, we might perhaps suggest that Stevie has some form of learning disability (without fits; ref. 8, p. 8), although if he has acquired the ability to read and write and draw with compasses this may be mild. Another possibility is that repeated head trauma may have contributed to his difficulties, since it is reported that his father called him a “slobbering idjut” and his disciplinary measures included physical blows when he was impatient with his son (8,140,192). Learning disability or mild traumatic brain injury might produce evidence of executive dysfunction, as indicated by hyperkinetic motor perseveration.

 

References

  1. Christensen AL, Goldberg E, Bougakov D (eds.). Luria’s legacy in the 21st century. Oxford: Oxford University Press, 2009.
  2. Ibid., pp. 122-145.
  3. Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Assessment Battery at bedside. Neurology 2000;55:1621-1626.
  4. Larner AJ. Frontal Assessment Battery (FAB): a pragmatic study. Neurodegen Dis 2011;8(Suppl 1):565.
  5. Larner AJ. Can the Frontal Assessment Battery (FAB) help in the diagnosis of behavioural variant frontotemporal dementia? A pragmatic study. Int J Geriatr Psychiatry 2013;28:106-107.
  6. Larner AJ. FRONTIER Executive Screen (FES). Poster 034, Association of British Neurologists meeting, Liverpool, 3-5 May 2017.
  7. Op. cit., Ref. 1, pp.130-131.
  8. Newton M (ed.). Joseph Conrad. The secret agent. A simple tale. London: Penguin Classics, [1907] 2007.
  9. McDonagh P. Idiocy. A cultural history. Liverpool: Liverpool University Press, 2008.
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