RESEARCH REPORTS

Neuropsychological Interpretation of the WAIS

Elbert W. Russell Veterans Administration Medical Center Miami, Florida

Abstract
The WAIS is the most consistently used test in neuropsychology even though it was not originally designed to measure the effects of brain damage (Lezak, 1983). There appear to be at least three reasons for this: 1) It provides a general measure of a person's intellectual level that can be compared to normal functioning. 2) It is the best constructed test, psychometrically, in neuropsychology. 3) It provides several subtests with scale scores which were simultaneously normed so that patterns can be obtained. Some of these patterns are discussed in this paper.

Intelligence Testing
Intelligence and ability tests have been developed over more than 70 years. The general psychometric requirements of such tests were determined through this long intensive investigation of intellectual abilities. As such, the requirements for such tests are not arbitrary. Neuropsychology has demonstrated that intelligence tests are in fact tests of the functioning of the associative areas of the brain. The psychometric requirements of such tests are produced by the nature of cortical association area functioning. This research helps resolve an ancient problem in intelligence testing which is obtaining a nonredundant definition of intelligence. What is intelligence that the test measures? Neuropsychology provides a nonredunant basis-the brain. The nonredundant criterion measure is, more exactly, brain (tissue) damage. When part ofthe brain is known to be greatly damaged-on the basis of arteriograms, CT scans or autopsy findings-a particular intellectual function is also found to be severely impaired. Intelligence can be defined as the effectiveness of the cortical association area functioning. Higher intelligence is produced by more effective functioning of the association areas of the cortex. This shifts the basic problem of determining the "nature of intelligence" from an impossible redundant psychological or sociological problem to that of brain physiology and genetics; that is, what physical conditions (and learning) provide for more effective functioning of the cerebral cortex. The WAIS is a very inadequate measure of overall intelligence, measuring only a small portion of the func-

tions known to reside in the various cortical association areas. For instance, since the work of Hebb (1941), it has been known that the functions related to the frontal association areas of the brain are not being measured. The verbal section of the WAIS has no measure of fluid intelligence and the performance section has no adequate measure of crystallized nonverbal functions. The WAIS also does not measure fluency or recent memory. Other neuropsychology tests are required for a thorough examination of brain functions. Thus a neuropsychological battery can be thought of as an extended intelligence test including areas of ability not covered by the WAIS. However, the scope of this paper is limited to the WAIS since it is such a widely used test. In using the WAIS, however, one must be aware that it is a very limited measure of intelligence. Nevertheless, the WAIS test is strongly affected by brain damage; however, often not in accord with the traditional idea of how damage affects this test. Consequently brain damage cannot, in most cases, be diagnosed from the patterns on the Wechsler tests alone. Different types of brain damage produce different patterns of effects on the WAIS. There is no one pattern which is produced by all forms of brain damage that is distinct from some functional problems. Consequently, there is no adequate way of separating the effects of functional problems from those due to some type of brain damage. For instance, mental retardation generally produces a low score on the Wechsler Test. Although mental retardation is sometimes produced by congenital brain damage, many types of mental retardation appear to be genetic rather than due to specific kinds of brain damage. Consequently, a brain damage pattern would not be expected to appear. There is no consistent difference between these types, of mental retardation and the overall reduction in intelligence produced by dementia. Another example is the schizophrenic pattern. Schizophrenia tends to produce variable effects on the WAIS. However, there is some tendency for the Verbal IQ to be higher than the Performance IQ. This is exactly the same as the pattern produced by some types of brain damage. Finally, a large discrepancy between Verbal and Performance IQ scores is not necessarily indicative of brain damage. College graduates often have a higher Verbal IQ and at times very much higher, than Performance IQ. Character disorders may have the opposite pattern of higher

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Performance and lower Verbal IQ. All of these patterns are duplicated by one or another form of brain damage. Consequently, it is almost impossible to diagnose brain damage from the Wechsler tests alone. However, this does not mean that the WAIS is not useful in the evaluation of brain damage. It can be quite helpful in conjunction with other tests of brain damage. Under certain circumstances it may help to determine the location and type of damage. As such, it is an integral part of the present Halstead-Reitan Battery, and serves a valuable function in the assessment of brain damage. One caution should be made at the outset in regard to the interpretation of the effects of brain damage on the WAIS. Increasing age produces a definite pattern on the Wechsler Test. This pattern is the one that Wechsler (1958) first described in terms of "hold" and "don't hold" subtests. Wechsler's "hold-don't hold" pattern was only partly correct. Actually this pattern is fairly similar to that produced by a diffuse, slowly progressive type of damage. One might say that aging is a slowly progressive form of brain deterioration. In any case, the practical effect of age on the Wechsler Test is that in dealing with the subtest patterns on the WAIS, the age scales should be used as they are corrected for age effects. Then effects of aging will not confuse the general picture.

Patterns Produced by Types of Damage

The first type of damage to be considered is that of generalized or mixed Chronic brain damage. In this type of brain damage, a pattern similar to the WAIS "hold" versus "don't hold" pattern occurs but it is very weak. The studies by Russell (1972b) on mixed types of chronic brain damage demonstrated that the general pattern is a reduction across the board with regard to all subtests. In this study the usual three factors (Nerviano, 1977) that are almost always derived from a factor analysis of the Wechsler tests were found. In the unrotatedWechsler tests there is essentially only one strong factor. This means that all of the Wechsler tests are affected by brain damage. In the rotated factors the usual following three factors were obtained: (1) Verbal factor, which includes all of the verbal tests with the exception of Digit Span and to some extent Arithmetic; (2) Performance factor, which includes all performance tests; (3) Digit Span factor, which loads primarily on Digit Span and to some extent on Arithmetic and Digit Symbol. However, only the loading of the Digit Span is consistently significant.

on the third factor. When one examines the correlations between the WAIS subtests and a criterion of laterality, it is evident that although several tests are somewhat related to the right versus left damage, nothing really approaches significance with the one exception of Digit Span. Apparently Digit Span is affected by chronic left hemisphere damage. (When the term left or right hemisphere is used, it is assumed that the person's left hemisphere is dominant.) In relation to chronic lateralized brain damage, there is no great differential effect related to Verbal versus Performance tests, and no effect on subtests with the exception of Digit Span. It should also be noted that the effect on Digit Span is not very strong although it does reach significance. As damage changes from an acute lateralized damage to chronic damage, the effects of acute damage which do make a difference on the Verbal and Performance scores gradually balance out so that as the damage becomes chronic (Russell, 1981), this difference between Verbal and Performance scores tends to disappear. In regard to individual cases, this balancing out does not always occur. Evidently, if there is focal damage directly in the speech area, the verbal tests are more impaired; otherwise there is very little differential effect on WAIS verbal tests. In the same manner, if the chronic focal damage is in the parietal area of the right hemisphere, the Block Design and Object Assembly may be affected. Chronic damage elsewhere in the right hemisphere will generally not differentially affect the WAIS.

AcuteL:lferalized Brain Damage

The effect of acute and rapidly progressive types of damage are quite different (Matarazzo, 1972; Russell, 1972a). The expected pattern related to Verbal versus Performance subtests is largely found in relationship to acute and rapidly progresSive types of damage. There are some variations which will be explained shortly. In general, patients with left hemisphere damage show a somewhat poor ability to deal with the verbal parts of the Wechsler tests. This can be expected since some left hemisphere patients are aphasic and have problems with the verbal items. It should be noted that, at least according to my perception, this effect on the verbal section is not simply due to the fact that the aphasic patient is having difficulty talking. The aphasic patient simply has lost his language ability, not the more external ability to express things verbally. He simply cannot "think" in verbal terms. It should be noted that Information, Comprehension, and Vocabulary are often affected by left hemisphere damage even when there is no aphasia. Similarities, contrary to the belief that brain damage affects abstract thinking, is only slightly more affected by acute left hemisphere damage than is Information or Vocabulary. Left hemisphere inferior temporal lobe damage appears to affect Information and
See WAIS Interpretation page 4

Chronic L:lferalized Damage

In regard to lateralized chronic brain damage, Russell (1972b) and other researchers (Matarazzo, 1972; Nervanio, 1972) found the same three factors as mentioned above. However, both Arithmetic and Digit Symbol were stronger

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Vocabulary more than Similarities. The pattern of low Vocabulary and Information and high Similarities often indicates left temporal lobe damage. In many cases of left hemisphere damage the effect of lateralization and fluidity cancel each other and the Verbal subtests are not more impaired than the Performance tests (Russell, 1979; 1980). Acute right hemisphere damage affects some of the performance tests much more than others. Consequently, not all of the performance tests are equally affected by right hemisphere damage. These differences in the effects of right hemisphere damage were found by many research studies (Russell, 1972a). Two of the performance tests are strongly affected by brain damage. These are Block Design and Object Assembly. Picture Arrangement is also affected, but to a lesser degree, by acute right hemisphere damage. The two other performance subtests, Digit Symbol and Picture Completion, are not specifically affected by right hemisphere damage since they are bilaterally affected. The conclusion is that, contrary to the effects of chronic diffuse damage, acute lateralized brain damage produces a definite pattern of damage on the various subtests. Block Design and Object Assembly are strongly affected. Picture Arrangement is moderately affected while Picture Completion is not greatly affected. Since Digit Symbol is affected by damage almost anywhere in the brain, it will be strongly affected by both right and left hemisphere damage. It should also be noted that in practice, temporal lobe damage may affect the Picture Arrangement more than the other subtests.

Slowly Progressive Diffuse Brain Damage

The third pattern which has been recognized in relationship to WAIS subtests is that ofa slowly progressive diffuse form of brain damage (Russell, 1979). As was mentioned before, this type of damage is somewhat similar to the effect of aging. Consequently age norms must be used to ensure that the pattern is not simply due to aging. Thus, there is a slowly progressive pattern of "hold" and "don't hold" tests beyond the aging pattern. This pattern is evidently related to Cattell's (1943) concept of fluidity or fluid and crystallized intelligence (Horn, 1976). Cattell thought that due to learning, fluid intelligence, which is natural or innate, gradually builds a store of well-learned information. This become crystallized intelligence. Fluid intelligence reflects an active processing of material (active thinking) while crystallized abilities only require retrieval of well learned material. Fluid intelligence is strongly affected by brain damage whereas crystallized intelligence is less affected. As was mentioned before, this distinction is roughly the same as that which Wechsler used in connection with "hold" and "don't hold" tests. Wechsler (1958) originally designated those tests that did not deteriorate

much with aging as "hold" and those that deteriorated more rapidly as "don't hold" tests. Neuropsychology has accepted this same terminology for the effects of brain damage as the Wechsler tests. The original "hold" tests (Wechsler, 1958) were Vocabulary, Information, Object Assembly, and Picture Completion. The "don't hold" tests were Digit Span, Similarities, Digit Symbol, and Block Design. Apparently Wechsler wanted an equal number of "hold" and "don't hold" tests in each of the verbal and performance areas. Further research has only partly supported his pattern. In regard to the Wechsler tests all of the verbal tests tend to be "hold" tests whereas the performance tests tend to be "don't hold" tests (Horn, 1976). Three tests are the strongest "hold" tests in the WAIS (Russell, 1979, 1980). These are Information, Comprehension, and Vocabulary. Arithmetic, Similarities, Digit Span, and Picture Completion tend to be moderate "hold" tests. The performance tests, except Picture Completion, are all tests of fluid ability and as such they are "don't hold" tests. Of these, the Digit Symbol and Block Design tests are the most greatly affected by slowly progressive diffuse damage. However, Object Assembly is also a quite strong "don't hold" test. The pattern that slowly progressive diffuse brain damage produced is roughly as follows (Russell, 1979, 1980): The Verbal tests are generally above the Performance tests. Information, Comprehension, and Vocabulary are higher than the other Verbal tests. All of the performance tests, except Picture Completion, tend to be lower than the verbal tests, and Digit Symbol and Block Design are the lowest tests of the entire battery. This type of pattern has been found in many studies. One should be warned that this pattern is not inevitably found in cases of slowly progresSive damage, especially in cerebrovascular disease. In fact, no particular pattern is invariably found with the type of damage of which it is typical. Too many other factors, such as the patient's original ability levels, are involved. The differential sensitivity of verbal and performance tests to brain damage in general means that assessment of lateralized damage does not follow a symmetrical pattern in which a to-points Verbal IQ is indicative of left hemisphere damage as a 10point lower Performance IQ indicates right hemisphere damage. Rather the difference is highly asymmetrical (Russell, 1984). With a known brain damaged patient a Verbal IQ that is any number of points lower than the Performance IQ is suggestive of left hemisphere damage (in a right handed person). On the other hand, the Performance IQ must be 20 or more points below the Verbal IQ to suggest right hemisphere damage. The space between these points is more suggestive of diffuse damage. Again these differences are only suggestive and must be supported by other tests to indicate latera1ized or diffuse damage. From this, the difficulty in diagnosing brain damage from the Wechsler tests alone is apparent. Perhaps the only subtest that should be used to help diagnose brain damage

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in general is a low Digit Symbol (Russell 1979, 1980) and even here it may not be depressed in some chronic types of damage. If the Digit Symbol is the lowest test on the battery, then brain damage might be suspected.

Subtest Scores
In this section the various subtests will be discussed from the point of view of their relationship to brain damage. These will be taken in Wechsler's order. Information is the first subtest. Generally it is a "hold" test and it is correlated highly with the Vocabulary test (Nerviano, 1977). Vocabulary and Information are more highly correlated than any other two subtests in the WAIS. Comprehension is also closely related to Information and Vocabulary although it is not quite as highly correlated with Vocabulary as with Information. These three tests can be taken together in a discussion of the effects of brain damage. All three of them represent both crystallized intelligence (Horn, 1974) and left hemisphere tests (Russell, 1979). All three are fairly strongly affected by any aphasic disorders but they are relatively unaffected by diffuse, slowly progressive damage. Since these three subtests are the least affected by diffuse damage, they can often be used to estimate an individual's prior intelligence. One can fairly safely assume that an individual's prior intelligence in a slowly progressive type of disease is represented by these tests as a minimal estimate: his intelligence was at least as high as these three tests indicate. Of course, there are exceptions to this but if we are estimating intelligence, these three tests may be used by themselves. The other tests are much more affected by brain damage; consequently they do not provide good estimates of a person's prior intelligence. If from other tests the patient appears to have left hemisphere focal damage, then these tests cannot be used to estimate the patient's previous level of intellectual ability. Rather, one must depend on the patient's highest level of education and occupation. The highest performance subtest score may also provide a very minimal estimate of previous ability. Since Arithmetic is moderately affected by dama~e, it is a moderate "hold" test (Russell, 1979). It is quite strongly affected by acute left hemisphere damage (Russell, 1972) and it is also affected by anxiety. Arithmetic is probably a fairly unreliable test, generally, and by itself of very little use except to determine the person's logical Arithmetic ability and possibly to indicate anxiety. The Arithmetic subtest is as much a test of logic as of the ability to calculate, since in some studies it is not highly correlated with a pure Arithmetic factor. Similarities is considered to be a measure of abstract versus concrete intelligence. One theory related to brain damage is that patients who are damaged will not think in abstract terms; thus Similarities should be rather strongly affected. My experience is that this theory does not hold up to any great extent. There is a slight tendency for brain

damaged patients to be more concrete. However, this concreteness is related to a generally reduced ability to deal with verbal material, abstract as well as concrete. If Similarities is higher than Vocabulary and Information, then left temporal lobe damage may be expected (Russell, unpublished data). There should be other indicators of left hemisphere damage on the Halstead-Reitan Battery to support this assessment. Similarities cannot be used by itself to indicate brain damage. Digit Span appears to be more affected by left hemisphere damage (including chronic damage) than any other test. In fact, in a study on chronic lateralized damage, Digit Span was the only subtest, either Verbal or Performance, that lateralized at all (Russell, 1972b). Research (Warrington, Logue, & Pratt, 1971) has demonstrated that Digit Span forwards is related to the left super marginal and angular gyrus. Thus an unusually poor Digit Span forwards almost always indicates damage near that area. In such a case, it is not a good measure of general attention since the rest of the brain may be functioning at a much higher level. One other effect related to Digit Span that should be noted is that there is apparently some tendency for brain damage to affect Digits Backwards to a greater degree than Digits Forwards. Consequently, when there is a large difference between Digits Forwards and Backwards with Digits Backwards being worse, one might expect brain damage, particularly left frontal damage. Apparently this is not a consistent finding. The Digit Symbol Test is the only test on the Wechsler scales that is fairly consistently affected by brain damage (Russell, 1979). As a result, the Digit Symbol test was placed in the general brain damage index for the Rennick version of the Halstead-Reitan Battery (Russell, Neuringer & Goldstein, 1970). Whenever the Digit Symbol is the lowest test, or even quite low compared to the verbal tests (using age norms) in the battery, brain damage should be suspected. Evidently Digit Symbol measures clerical speed; it is not so much a memory test as it is a clerical speed test. In one study (Lansdell, 1971), the Digit Symbol loaded on the same factor with the clerical speed test taken from the Differential Aptitude Test. Consequently, the Digit Symbol appears to be a good measure of psychomotor speed. A consistent finding is that in brain damage of almost every kind (with the exception of some types of old static damage), psychomotor speed is reduced. As such, Digit Symbol, which is very sensitive to such speed, is almost always affected. Picture Completion appears to measure a bilateral function (Russell, 1972) and is not any more affected by right hemisphere damage that left. This may be due to the way in which Picture Completion is scored. Scoring of the Picture Completion test may be done either by pointing to the missing part of the picture or by naming that part.
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Thus, patients with aphasia but with an intact right hemisphere can still obtain a fairly good score on this test simply by pOinting to the missing part even though they cannot name it. The Picture Completion test also appears to be a moderate "hold" test and is not strongly sensitive to slowly progressive damage (Russell, 1979). In fact, it is the only performance "hold" test. By contrast, Block Design is highly sensitive to slowly progressive damage. According to some research (Russell, 1979) it is almost as sensitive as Digit Symbol. It should be noted that Block Design also directly measures a function that is localized in the right parietal lobe of the brain. Consequently, right hemisphere damage affects Block Design very strongly. Thus Block Design may be strongly impaired by either slowly progressive damage or acute right hemisphere damage. This is also true of most of the visual spatial tests of brain damage such as the Bender-Gestalt or the Graham-Kendall test. Picture Arrangement is also affected by slowly progressive damage and it tends to be affected somewhat more by right hemisphere damage than left (Russell, 1979). However, that effect is not as strong as for Block Design and Object Assembly. Picture Arrangement is evidently related to right temporal lobe damage. If Picture Arrangement is the lowest test in the WAIS, with perhaps the exception of Digit Symbol, right temporal damage is implicated. In closed head trauma often both temporal lobes are injured. Thus, in head trauma, Picture Arrangement may appear to be affected by left temporal damage when, in fact, both temporal lobes are involved. Object Assembly is highly correlated with Block Design, particularly with brain damaged patients (Nerviano, 1977). It is affected by slowly progressive damage and is almost as sensitive to such damage as Block Design (Russell, 1979, 1980). It also measures a right hemisphere function. Clinical experience indicates that when there is a difference between Block Design and Object Assembly, with Object Assembly being more impaired, the damage is often primarily in the inferior parietal or temporal lobe. The conclusion of this study is that the WAIS, when used in conjunction with other tests of brain damage, such as the Halstead tests, is a valuable instrument for assessing brain damage. However, used by itself, it is not a good diagnostic tool for determining either the existence of brain damage or laterality. Almost any brain damaged pattern that

is found on the WAIS could be produced by several types of other conditions, both functional and organic. Thus, the proper use of the Weschlser Intelligence tests, when assessing brain damage, is in conjunction with a battery of brain damage tests.

References
Cattell, R. B. (1943). The measurement of adult intelligence. Psychological Bulktin, 40, 153-193. Hebb, D. o. (1941). Clinical evidence concerning the nature of normal adult test performance. Psychological Bulletin, 38, 593 (Abstract). Horn, J. L. (1976). Human abilities: A review of research and theory in the early 1970s. Annual Review of Psychology, 27, 437-485. Lansdell, H. (1971). A general intellectual factor affected by temporal lobe dysfunction. jou17Ul1 of Clinical Psychology, 27, 182-184. Matarazzo, J. D. (1972). wechsler's measurement and appraisal of adult intelligence. (5th Ed.) Baltimore: Williams & Wilkins. Nerviano, V. J. (1977). Factorial structure of the Wechsler Adult Intelligence Scales: A critical reevaluation. )SAS Catalog of Selected Documents in Psychology, 7, 63. Russell, E. W. (1972a). Effect of acute lateralized brain damage on a factor analysis of the Wechsler-Bellevue Intelligence Test, Proceedings of tbe 80tb Annual Convention of tbe American Psychological Association, 7, 421-422. Russell, E. W. (1972b). A WAIS factor analysis with brain damaged subjects using criterion measures. jou17Ul1 of Consulting and Clinical Psychology, 39, 133-139. Russell, E. W. (1979). Three patterns of brain damage on the WAIS. journal of Clinical Psychology, 35,611-620. Russell, E. W. (1980). Fluid and crystallized intelligence: Effects of diffuse brain damage on the WAIS. Perceptual and Motor Skills,51, 121-122. Russell, E. W. (1981). The chronicity effect. journal Of Clinical Psychology, 37, 246-253. Russell, E. W. (1984). Theory and development of pattern analysis methods related to the Halstead-Reitan Battery. In P. E. Logue & J. M. Schear (Eds.) Clinical Neuropsychology, A Multidisciplinary Approach. Springfield: Charles C. Thomas. Russell, E. W., Neuringer, C. & Goldstein, G. (1970). Assessment of Brain Damage. A Neuropsycbological Key Approacb. New York: Wiley-Interscience. Warrington, E. K., Logue, V., & Pratt, R. T. C. (1971). The anatomical location of selective impairment of auditory-verbal short-term memory. Neuropsycbologia, 9,377-387. Wechsler, D. (1958). The Measurement of Adult Intelligence. (4th Ed.) Baltimore: Williams & Wilkins.

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