Right Hemisphere
Syndrome: Characteristics
and Assessment
Susan T. Jackson
October 1, 2010
Pathophysiology

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No obvious localization of language or
communication in the right hemisphere.
Reasons:
 Gross classification of lesion location (anterior
vs. posterior)?
 More white matter and less gray matter,
therefore more intrahemispheric connections
between neurons in the right hemisphere?
Speculation: complex neuronal networks are
necessary for various communicative processes
affected in RHD – discourse comprehension;
interpretation of humor, affect, sarcasm –
damage to networks that integrate info from
various sources?
Nature and Differentiating Features
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What is normal vs. abnormal? Boundaries not
always clear; consult with family members re:
pre- vs. post-stroke behavior in the areas of
pragmatics and cognitive abilities
Blake (2006) found that “tangentiality,
egocentrism, and extremes of quantity (too
much or too little) are clinically relevant
characteristics of discourse produced by adults
with RHD.” That is, these three characteristics
were useful in distinguishing healthy older adults
from those with RHD.
50% of a nonselect group of those with RHD had
verbal communication impairments; 95% of
those with RHD in a rehab unit had some type of
cognitive or communicative deficit
Nature and Differentiating
Features
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May exhibit hyporesponsivity (short answers,
lack of facial expression or prosody) or
hyperresponsivity (verbose, doesn’t
communicate main idea, tells inappropriate
jokes)
Disorders of attention, visuoperception, and
learning and memory are the most commonly
diagnosed deficits
Problems surface when multiple interpretations
are possible and with increased demands on
cognitive resources (time constraints, having to
generate inferences, and having to consider
another person’s point of view)
Linguistic, Extralinguistic, and
Non-linguistic Deficits
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Linguistic deficits
 Least common
 Includes word-finding difficulty and auditory
comprehension deficits most often
Extralinguistic deficits
 Difficulty with figurative language, reduced accuracy
of core concepts and inferences, reduced eye contact,
reduced sensitivity to emotional prosody, reduced
appreciation of shared knowledge, reduced use of
prosodic features, reduced ability to interpret humor
Nonlinguistic deficits
 Visual perception problems, left neglect, attention
deficits
Communication Deficits

Figurative/nonliteral language
 idioms – www.idiomsite.com
 metaphors (e.g., Her skin is silk)
 indirect requests – better in natural contexts
 Impairments in comprehending figurative
language could reflect a coarse coding
deficit (distant semantic features of words
are not activated) – discuss Tompkins’
(2008) info about multiple phases of
comprehension (construction phase and
integration phase) and about construction
and integration deficits
Communication Deficits

Inferencing
http://teach.fcps.net/talk/lesson_display.asp?lessonID=89
 Generation and interpretation
 Difficulty depends on type of inference required
(predictions and character emotions are more impaired;
context can aid interpretation)
 Difficulty comprehending when multiple interpretations
are possible and/or when an initial interpretation must be
revised. Coarse coding deficit hypothesis explanation.
Suppression deficit hypothesis (Tompkins) explanation –
those with RHD can generate multiple interpretations but
have difficulty choosing the most plausible.
 Difficulty may arise when metacognitive demands are
higher (e.g., having to attribute emotions to a character
that are at odds with the comprehender’s emotions)
 Difficulty describing inferentially complex pictures
Communication Deficits
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Discourse organization (macrostructure)
 Difficulty stating or identifying main ideas
 Reduced cohesion of discourse production
 Disorganized discourse
 Deficits not as apparent when discourse is based on
scripts
Humor
 May have a preference for physical, slapstick humor
 May tell inappropriate jokes (not sensitive to partner or
situation)
 Impairment in the reinterpretation of incongruous info
to create coherence between the punch line and the
preceding text (similar to difficulties in inference
revision). Difficulty choosing an appropriate punch
line or explaining why a punch line is funny.
Communication Deficits

Pragmatics
 Take fewer turns and talk more about
themselves
 Prolong conversations and don’t heed cues
from partner
 Difficulty using context to interpret an indirect
request or a literally false statement (sarcasm
or lie)
 Difficulty detecting tangential statements that
block the flow of conversation
 Theory of mind explanation of pragmatic
deficits; RHD pragmatic impairments could be
associated with problems associated with
multiple interpretations
Communication Deficits

Prosody
 Two types: linguistic and emotional/affective
prosody
 Difficulty with comprehension and/or
production of affective and/or linguistic
prosody (aprosodia). Person with RHD has
flat, monotone speech. Difficulty interpreting
sarcasm (conflict between linguistic info and
prosody).
 Aprosodia is not a common sequel of RHD
(present in ~30% of one RHD sample)
 See SID-2 article by Leon & Rodriguez (2008)
Communication Deficits
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Affect
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Hypo- or hyperaffective
Difficulty inferring mood from a situation or
personality characteristics
Person with RHD can make use of context to help
interpret emotion
May be less effective at verbalizing emotion
No clear evidence that RHD impairs negative
emotions more than positive ones
Attention and Perception
Deficits
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Attention
 Attention deficits may be due to reduced attentional
capacity, difficulty assessing how much attention to
allocate, and/or problems with allocating the needed
amount of attention
 There are different types of attention (arousal,
vigilance, sustained, selective, divided); there’s more
difficulty with having to do two things at once
 Impaired attention may have a negative impact on
comprehension, producing a cohesive narrative
Anosognosia = denial of illness
 Sometimes not outright denial, but reduced
awareness of deficits or limitations caused by the
deficits
 May make the person a less than ideal tx candidate
Attention and Perception Deficits

Neglect – an attentional disorder in which sensory info is not
consciously processed by the brain
 Neglect usually affects the side of space opposite the brain
lesion – therefore, left neglect in those with RHD
 The area that is neglected is not absolute (can be to the left
of a person’s midline, to the left of an object, can be affected
by presence of other stimuli)
 Visual neglect is most common and can affect
communication – ignore stimuli (people, objects) in left hemispace when having a conversation, miscomprehend written
info because do not read left side of page, wide left margins
when writing
 Those with persisting neglect tend to have large lesions
 There is evidence of unconscious processing of neglected
items (house example from text, priming studies)
 Those with an initial diagnosis of neglect (even if it resolved)
had more difficulty with discourse level language tasks than
those who never had neglect – because of decreased
attention?
Attention and Perception
Deficits

Visuoperception
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Can cause difficulties in reading and writing
(misperceptions of letters and words and
disorganized writing)
Can cause difficulty on confrontation naming
tasks and picture description tasks
Prosopagnosia = facial recognition deficit
Cognition
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Sequencing
Organizing
Problem solving
Reasoning
Assessment: The Basics
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Gather medical, biographical, and
communicative/cognitive/perceptual data
Goals of formal assessment
1.
2.
Evaluate communication strengths, weaknesses,
and needs
When impairments are identified, probe
potentially contributing communicative,
perceptual, and cognitive factors
Published Tests of RHD
Communication Impairments
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Mini Inventory of Right Brain Injury – 2nd
edition (MIRBI-2)
The Burns Brief Inventory of Communication
and Cognition: Right Hemisphere Inventory
Rehab Institute of Chicago Clinical
Management of Right Hemisphere
Dysfunction – 3rd edition (can be purchased for
$50 from the RIC book store)
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Right Hemisphere Language Battery
Assessment of
Communication: Pragmatics
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During the interview process you can assess
the responses for appropriateness of content,
verbosity, paucity of output, tangentiality,
egocentrism, irrelevance, turn-taking, eye
contact
The Pragmatic Protocol (Prutting & Kirshner,
1987) – see handout
The Profile of Communicative
Appropriateness (Penn, 1987) – see handout
Assessment of
Communication: Prosody
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Aprosodia Battery (Ross et al., 1997) – journal
article – assesses comprehension and
production of prosody (tape-recorded stimuli
described; no tape)
Battery of Emotional Expression and
Comprehension (Cancelliere & Kertesz, 1990) –
journal article
Florida Affect Battery (Bowers et al., 1998);
published by the University of Florida –
assesses perception/comprehension of affect
and prosody; can be purchased for $200
www.neurology.ufl.edu/forms/fab_manual.pdf
Assessment of Communication
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Figurative/nonliteral language
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Inferencing
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Assesses comprehension of idioms, metaphors,
and indirect requests (informal)
Ask person to describe inferentially complex
pictures – score Cookie Theft picture description
using Myer’s scoring system (see handout)
Use DCT to assess comprehension of discourse –
including ability to comprehend implied info
Discourse organization
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Elicit descriptive, narrative, and/or conversational
discourse and rate organization of output
Assessment of Attention
and/or Neglect
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Behavioural Inattention Test (BIT; Wilson et al., 1987) assesses attention and neglect
Test of Everyday Attention (TEA; Robertson et al., 1994)
Vigilance – some published computer tasks are available;
measure RT and accuracy
Selective attention – assess using Stroop Color-Word test
http://faculty.washington.edu/chudler/words.html#seffect, feature
conjunction tasks (e.g., identify all the red triangles when there
are red and black triangles and red and black diamonds)
Sustained attention – can be assessed using cancellation tasks
or during conversation
Divided attention – can be assessed by asking the person to do
two things at once (e.g., count while canceling targets on a
printed page)
Assessment of Attention
and/or Neglect
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Can assess neglect using cancellation tasks,
line bisection, drawing a symmetrical item
(copying and from memory), describing a picture
scene, reading a paragraph, writing a few
sentences
Look for behaviors such as grooming or
dressing one side of the body or bumping into
doors/walls on left (could use the Catherine
Bergego Scale) that might suggest neglect
Assessment of Cognition
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Reasoning and problem solving
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Functional Assessment of Verbal Reasoning and
Executive Strategies (FAVRES; MacDonald,
2005)
Sequencing and organizing
Memory
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Rivermead Behavioural Memory Test – 3rd ed.
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Language Disorders of Adults