Caspar’s Cases #6 “Apraxia or not Apraxia and the Impairment of the patient”
Distressing Differential Diagnosis delayed – cases and complications….
The ‘best laid Research Plans…’ [1]
As I mentioned previously[2] my PhD research was on ‘apraxia’, an inability to effectively plan and learn patterns of movement, due to brain damage.
I had a chance to present a possible case study of apraxia to the Neurology Department’s Grand Round. However when I asked the Chief Psychologist, Dr David Dennison, if he had any feedback about that, he said, somewhat cagily:
“Sorry Caspar the consensus was that a Korsakoff’s syndrome is too complicated and transitory for your research, and you didn’t actually demonstrate the apraxia symptoms…”
‘Gibson didn’t give me a chance to show Mr Edwards’ cigarette lighting routine’. I sounded like a pathetic windger rather than the professional I aspired to be.
Always the conservative professional, Dr Dennison pointed out the painfully obvious:
“Well the fact is you will need a sample of at least 6 cases that can be sufficiently documented and you’ll have to keep going interviewing and testing until saturation of similar data, within and across subjects”.
‘Right – OK I understand. I was just trying to get a demonstration that it is possible for a differential diagnosis of apraxia, … but you’re right the transitory nature of Korsakoffs undermines using that case in my thesis.’
“Also the patient and or their Guardian, has to be able to agree to being used as subjects in your thesis research – you can’t just grab patients and present them for your research….”
‘Yes I know - but I need to screen them through the Grand Round before I can consider them as subjects for my research!’ Dennison shrugged his shoulders:
“Well at least you have to get them prepared properly and informed then we’ll decide if they go to the Grand Round and then we’ll decide if they are suitable for your research” and then he left me frustrated.
So I checked out that I had the latest in the ongoing escalation of ethics permissions forms for both the Hospital and the University (it was a lot of a paper) and I checked the meeting schedules, as I had to submit to the respective ethics committees a month before their infrequent meetings.
Somewhat deflated, I went back to the wards seeking referrals and kept bothering the Deputy Chief Physio (Ms Mavis Morton). She was sufficiently tolerant and generously tried to smooth out my despair about the Grand Round fiasco.
“Come on Caspar it wasn’t that bad” she tried to comfort me, “I’ve seen a lot worse - once Gibson takes a dislike to you or your approach you’re in for it big time regardless of how good your presentation or your clinical expertise. So let’s move on and I’ll keep an eye out for likely cases for you – OK?”.
‘And I’m not going to jump into the Gibson’s lion’s den again any time soon. Plus I have to get Dennison to agree to support my ethics committee submissions and witness the signature of each patient…’ She gave me a coffee and a parental-like pat on my shoulder. It would be a while till I bothered her again.
Searching further afield for more cases
As I was obviously getting frustrated trying to find suitable patients and so wearing out my welcome with the tolerant Physios and Nurses at the Royal Central Hospital, I got Dr Dennison to write me a referral letter to the Commonwealth Rehabilitation Centre, out in the suburbs. I was keen to get to meet the legendary Medical Director there (Dr Louis Langton), who himself had a severe ambulatory disability. Sure enough he’d heard of my interest in searching for Apraxia. But his open door did not come without strings attached. He wanted me to be his de facto on-call Neuro-Psychologist because it was expensive to pay for consulting Psychologists and they were seldom proficient in the relatively new field of neuro-psychology. I insisted that I was not that proficient professional he wanted, but he insisted that in lieu of someone more proficient, that under his and Dr Dennison’s supervision, I would be sufficient.
There was one other consolation, as I got out of my car, I heard:
“Hey Caspsar! – what brings you out here – hiding from the glare of the Gibson & Grayson game?” came a familiar voice of Dr Malcolm Marginson, now the duty Psychiatrist out in the sticks, about to drive back to the city in his new expensive car.
‘You beaudty!’ I smiled at his sporty car– ‘I see you’ve cracked the big time Mac’ which was really a sarcastic gibe at his new posting out of the main stream Psychiatry circles.
“Beggers can’t be choosers – as you’d know Pearson!”
He was right as usual and proved to be not only a friendly face but he soon started sending me referrals.
While Dr Langton had me seeing almost every patient in the Rehab program for “routine checks on rehab goals”, Mac Marginson was more astute and referred me potential Apraxia cases.
Will Mrs Bucci cut it?
Sure enough Mac was a useful contact and helpful as usual, and when I visited his office he introduced a potential patient.
“Caspar – this is Mrs Bucci, a lovely hair-dresser and friendly person you should get to know. Shirley this is my friend Caspar Pearson and he’d like to ask you some questions. Would that be OK?”
‘Hello Mrs Bucci, how are you?’
“Not bad thank you – but they have me here for the …thing. But I don’t want it” she spoke quite well, despite the severe facial scaring from some rash or pox, and a frown.
It turns out that she had contracted Herpes during recovery from a hysterectomy in a private hospital and due to various complications suffered a stroke from a post-op blood clot.
‘Were you a hair-dresser Mr Bucci?’ she nodded, ‘OK so can you tell me what this is please?’ I handed her the scissors which had been conveniently sitting in Mac’s desk.
“Oh yes that’s the … thing - you use to…shorten the …” (she was gesturing around her hair with a snipping action of her fingers).
‘Yes that’s right Mrs Bucci you use then to cut hair – so can you tell me what they are please?’
“Yes – I know – it’s … something I used at work….a …” she was obviously anomic and very frustrated in her incapacity to say the common word needed.
‘That’s alright Mr Bucci – I know it must be very frustrating’ I tried to calm her.
“It’s not there… the thing- I want to… you know…” This time Mac Marginson rose to the aid of the patient, smiling friendly and bid me to leave it at that.
“Come now Mrs Bucci don’t worry, we’ll get you a nice cup of tea in your ward.” As he shepherded her in her walking frame out to the Nurses station.
On his return: “She’s recovering her hemiplegia quite well after 4 months here, but I’ve been referred her for the anxiety and depression secondary to the anomia.”
‘Was the clot sub-dural?’ – he nodded ‘And how many months ago was the stoke?’
“Six months, she had 2 months post op isolated due to the herpes and has not recovered well with some rashes and facial scaring which doesn’t help her self-esteem as a hair-dresser in a beauty salon.”
‘It’s kind of you to think of me mate, but I’ll really need to check out if there’s sufficient signs of apraxia as against the anomia’ he nodded.
“I wouldn’t bother you if I hadn’t done a bit of testing on her myself”
‘What now you’re doing my job for me….’ We laughed.
“Ha – you laugh - As it happens I have a new beta-max video camera and recorder in an interview room with a one-way mirror which you can use so we can get some evidence without a Grand Round audience to deter us”.
‘My- you are a saviour – not just a shrink with a good bed-side manner!’ he smiled.
Sure enough Mac had done his homework and when we had Mrs Bucci’s son’s approval to do the video and testing for my thesis it was hopeful. As she had been a hair-dresser I got hold of some electric clippers with attachments, a cutthroat razor, scissors, comb, and a brush. We set them up on a tabl in the video room with a mirror on a stand.
As I needed a hair cut and beard trim I asked her:
‘Thanks for coming here, Mrs Bucci, do you think you can cut my hair or trim my beard please?’ Sure enough she took command straight away when I handed her a barber’s cloth and clippers then sat in front of the mirror. Despite a bit of hesitation and weakness in her left hand she began to use the clippers on my beard and gave me a brief but acceptable beard trim.
‘Thanks so much Mr Bucci, it feels good’ I said shaking off the cloth. ‘Can you cut off my mullet at the back please?’
She looked puzzled and hesitated. ‘Which of these would you use to cut my hair?’ she stared at the array of implements on the table in front of us.
‘What are these?’ I gestured to the scissors. She said “Yes I know these are ….”
‘Scissors’ I said handing her the scissors, “Yes..” she said delighted as she took them slowly and began to snip in the air. The sound and feel of the cutting action seemed to alert her to what to do, so she moved closer to my head and I turned to allow her access to my neck. But then she hesitated and kept looking puzzling at them snipping in the air.
‘OK Mrs Bucci no worries take your time – I’m here to give you a go at practicing your art of hair cutting.’ But she stopped scissoring and looked at me with a tear in her eye:
“I don’t … I can’t…”
“Alright take your time, you can do it as I’m sure you’ve cut hair many times” chipped in Mac from behind the video camera. But no action from her – she just stood there staring at the back of my head and then looking at the scissors.
‘OK Mrs Bucci what about combing my hair to get it ready for a cut please.’ I gently took the scissors from her hand, and gestured towards the tools on the table. Although she went to the table she picked up the clippers and looked at them.
‘OK what are they? Are they the comb?’
“No – I think it’s …. What word did you call it?”
‘That’s the clippers, not what you need to comb my hair’ I gently took the clippers and put them back on the table. ‘Can you show me the comb and how to comb my hair please?’
She hesitated and looked at me with a tear in her eye, so I handed her the comb and said:
‘Not to worry please don’t cry Mrs Bucci – here see if this helps’
She took the comb and automatically strummed the tines with her thumb giving that sort of musical rising run of faint notes. I saw her eyes clear a bit as she slightly smiled with the familiarity of the feel of the comb.
‘Good let’s have go at my messy hair please’ she hesitated and looked at me through the mirror so I turned and gently took the comb and moved her hand up & down then slowly guided it towards my head whereby she moved the comb into the hair and smoothed in downward then took the hair in her left (weakened slightly hemiplegic) hand and started to automatically comb my hair.
‘Great thanks, now I’m ready for a hair cut please’ and I gently took the comb from her.
‘So what do you use to cut hair?’ she hesitated.
“That one …” she pointed to the scissors.
‘Great – so can you show me how to cut the hair please?’ She picked up the scissors and snipped in the air – this time a bit more confidently but her left arm was not doing as she wanted and she couldn’t grasp the hair to cut it so she got frustrated and stopped short of actually cutting my hair.
‘OK – sorry Mrs Bucci I’m sure you can do it next time…’ We took her back to the ward where her son was waiting.
“What’s happening?” he seemed miffed, although he gave us permission to interview her for my research he didn’t realise we’d try a hair cut.
‘No worries Mr Bucci we were trying to get your Mum to practice hair cutting again…’
“Nah – she tried last week on me but she hasn’t got it anymore” he gestured to the straggly hair half cut irregularly on the right side of his head.
The Moral of the Story
Mac and I conferred as we reviewed the video.
“Not sure if you sufficiently demonstrated the differential diagnosis of agnosia[3] from the anomia, and whether this uncertainty contributed to the lack of hair cutting, rather than apraxia” Mac said in his matter of fact manner.
He was right – not a convincing case study.
Again there is an unfortunate ending to the story of this patient. After another attempt to test her memory and use of barber’s tools her son got angry and demanded we stop frustrating her. He eventually discharged her from the Rehab Centre before sufficient progress on her recovery from hemiplegia and anomia. We never heard from her again.
So I had a video of an inconclusive case study, and an uneasiness about the efficacy of my methods. Certainly I needed more cases. I also now knew the frustrating process of testing for apraxia is in-and-of itself stressful for the patients and the perpetrator!
Perhaps it is like Heisenberg's uncertainty principle: the process of assessment is an intervention which changes the subject we are assessing.
[1] I write these notes so that others may learn from my experience and reflect on my lessons learned from these cases from a burgeoning practice of psychology. I share these events and analyses of the people and psychology – recounted as best I can, given the efflux of time and the constraints of confidentiality. So the names and places which appear herein have been changed to cover for the concerns of clients and institutions.
NOTE: All images are from Substak.com photo gallery.
[2] Caspar’s cases #4: “Andrea the Autodidact” and Caspar’s cases #5: “Apraxia and the imperfect patient”
[3] Although she hesitated to identify the comb, she did recognise it when she held it and strummed the tines; also she knew the feel and sound of the scissors as she did the cutting movement with them. She did have anomia, difficulty saying the names of the tools. But was this sufficiently differentiated from apraxia?