Journal of Clinical and Experimental Neuropsychology, 27:953966, 2005

Copyright Taylor & Francis Ltd.

ISSN: 1380-3395
DOI: 10.1080/13803390490919092

Is a Perseveration a Perseveration? An Evaluation

of Cognitive Error Types in Patients with
Subcortical Pathology

1380-3395
NCEN
Journal
of Clinical and Experimental Neuropsychology
Neuropsychology, Vol. 27, No. 08, August 2005: pp. 124

Perseverations
K.
L. Possin et and
al. Intrusions

KATHERINE L. POSSIN,1 J. VINCENT FILOTEO,2 SCOTT

C. ROESCH,3 VANESSA ZIZAK,2 LAURIE M. RILLING,4
AND JENNIFER D. DAVIS5
1

SDSU/UCSD Joint Doctoral Program in Clinical Psychology, San Diego, CA,

USA
2
University of California, San Diego and the VASDHS, San Diego, CA, USA
3
San Diego State University, San Diego, CA, USA
4
UT Southwestern Medical Center
5
Brown Medical School
This study investigated several constructs of executive functioning in a group of 77
patients with subcortical pathology. Specifically, we examined the validity of categorizing perseverative errors as recurrent, stuck-in-set, or continuous, as proposed by Sandson and Albert (1984). A principal components analysis of 2 measures of
recurrent perseveration, 2 measures of stuck-in-set perseveration, and 2 measures of
intrusive errors yielded a 2 component solution with stuck-in-set perseverations and
intrusive errors loading on Component 1, and recurrent perseverations loading on
Component 2. Presence of a continuous perseveration on a graphomotor test was significantly associated with higher factor scores on Component 1, but not Component 2.
The stuck-in-set perseveration and intrusion component was associated with the
majority of the other neuropsychological tests administered, including tests of executive function and memory. The recurrent perseveration component was not associated
with the other measures of cognitive functioning. Presence of a continuous perseveration was associated with executive function but not memory measures. This study provides evidence that recurrent perseverations are distinct from the other types of
perseverative and intrusive errors, and that stuck-in-set and intrusive errors are good
indicators of general cognitive functioning in patients with subcortical pathology.

Historically, the development of neuropsychological tests has been based on the assumption that the level of absolute performance provides useful information about the cognitive
domains assessed (Lezak, 1995; Reitan & Wolfson, 1993). It is well known, however, that
careful observation of behavior during the process enroute to a solution is also likely to
provide useful information (Kaplan, 1988; Luria, 1966). The observation and characterization of error types is one way to monitor the process that patients use to perform various cognitive tasks, and the use of this type of information has lead to a better
Received 3 October 2003; accepted 4 August 2004.
This research was supported in part by National Institute of Neurological Disorders and Stroke
Grant R01 41372 to J.V.F.
Address correspondence to Dr. Katherine Possin, SDSU/UCSD Joint Doctoral Program in
Clinical Psychology, 4030 Haines St., Unit E, San Diego, CA, 92109. E-mail: kpossin@ucsd.edu

953

954

K. L. Possin et al.

understanding of the nature of the cognitive deficits in different neurological disorders

(Walsh, 1987).
The measurement of error types is incorporated into some standardized neuropsychological tests, such as the Wisconsin Card Sorting Test (WCST; Berg, 1948; Heaton,
Chelune, Talley, Kay, & Curtiss, 1993). In addition to providing scores of overall success
(e.g., number of categories completed), the WCST provides an assessment of specific
types of errors, such as perseverative responses and set losses. Likewise, the California
Verbal Learning Test (CVLT; Delis, Kaplan, Kramer & Ober, 2000; Delis, Kramer,
Kaplan, & Ober, 1987) assesses not only the number of words recalled, but also measures
qualitative aspects of memory, including error types such as perseverations and intrusions.
The assessment of error types has also been a growing focus in the development of newer
standardized tests, particularly those that evaluate executive functions (Delis, Kaplan, &
Kramer, 2001). Successful performance on executive function tasks requires a variety of
both fundamental cognitive skills and higher-level executive functions. Thus, the analysis
of error types is an integral part of executive function assessment.
One error type that has commonly been studied in cognitive assessment is perseveration. In general, a perseveration is the inappropriate and unintentional persistence of a
behavior, and is believed to be an index of executive functioning (Lezak, 1995). Since
Neisser first introduced the term in 1895, perseveration has been associated with a variety
of neurological diseases and syndromes (for reviews see Hotz & Helm-Estabrooks, 1995a;
Sandson & Albert, 1984) and considered to be a reliable sign of brain damage when committed in multitude (Allison, 1966). In the past, researchers have attempted to operationalize
this error type by delineating categories of perseverative behavior (Hotz & HelmEstabrooks, 1995a, 1995b). For example, Sandson and Albert proposed a taxonomy of
perseverations based on an extensive literature review encompassing a wide range of
tasks, patient populations, and previous taxonomies. Three specific types of perseverations were proposed in their taxonomy. Stuck-in-set perseveration is an inappropriate
maintenance of a current category or framework. These authors suggest that this type of
perseveration results from a dissociation of actions from intent and is related neuroanatomically to frontal lobe damage. Recurrent perseveration is the unintentional repetition,
after cessation, of a previously emitted response. In contrast to a stuck-in-set perseveration, a recurrent perseveration falls within the appropriate task framework, and is only an
error because it is a repetition within that framework. Sandson and Albert postulate that
the underlying process of recurrent perseveration involves a post-facilitation of memory
traces and find that it is related neuroanatomically to posterior left hemisphere damage.
Continuous perseveration is the inappropriate repetition, without interruption, of a current
behavior. They suggest that it is caused by a disturbance in motor output and that it is
related neuroanatomically to basal ganglia damage.
Other error types that have been used to better characterize patients neuropsychological test performances are intrusion errors. These types of errors, however, have been
inconsistently defined in the literature, with descriptions of these error types often overlapping with the definitions of perseverations. For example, Loewenstein and colleagues
(Loewenstein, Wilkie, Eisdorfer, Guterman, & Berkowitz, 1989) defined five types of
intrusions: test intrusions are responses related to the category or content of a previously
administered distractor task; shift intrusions involve material from the immediately preceding distractor task; conceptual intrusions are conceptually similar to an appropriate
response; confabulatory intrusions consist of a single percept combining two appropriate
responses; and unrelated intrusions are responses unrelated to appropriate responses on
any task given. According to Sandson and Alberts (1984) taxonomy, test and shift

Perseverations and Intrusions

955

intrusions comprise stuck-in-set perseverations, whereas conceptual, confabulatory, and

unrelated intrusions are not reflected in their taxonomy. Similarly, Delis and colleagues
(1987; 2000) define intrusions on the CVLT-I and II as responses not on the current target
list, and according to Sandson and Alberts (1984) taxonomy, this definition also incorporates stuck-in-set perseverations by including responses on a previous target list. Doubleday and colleagues (Doubleday, Snowden, Varma, & Neary, 2002) described one type of
perseveration, closely corresponding to Sandson and Alberts continuous perseveration,
and three intrusion types that are (a) related to previously presented test material, (b)
semantically associated with the test material, and (c) not related to preceding test material. This first intrusion type subsumes Sandson and Alberts recurrent and stuck-in-set
perseverations, while the latter two are not included in their taxonomy. Thus, as can be
seen, there has been some confusion and inconsistencies in the literature as to how different types of perseverations and intrusions are defined.
Despite the inconsistent definitions in the literature, however, the use of both perseveration errors and intrusion errors have lead to a better understanding of the neuropsychological deficits associated with various patient populations. For example, Sandson and
Albert (1987) applied their taxonomy to the behavior of participants with left hemisphere
damage, right hemisphere damage, or Parkinsons disease (PD). They found recurrent perseveration to be associated with left hemisphere damage, continuous perseveration with
right hemisphere damage, and stuck-in-set perseveration with PD. Butters, Goldstein,
Allen, and Shemansky (1998) found that participants with multiple sclerosis or Huntingtons disease (HD) demonstrated higher frequencies of perseverations than participants
with Alzheimers disease (AD) on the Information and Vocabulary subtests of the Wechsler
Adult Intelligence Scale (Wechsler, 1955), with perseverations defined as a combination
of the stuck-in-set and recurrent types. They concluded that these qualitative differences
may be important for distinguishing between subcortical and cortical dementias. Using
discriminant function analysis with error types and learning characteristics of the CVLT
as predictors, Kramer, Levin, Brandt, and Delis (1989) correctly categorized 76% of
patients with PD, HD, and probable AD. Intrusions, recurrent perseverations, and rate of
forgetting were the most discriminating variables. Patients with AD and Korsakoff disease
have been found to make comparable levels of intrusion and perseveration rates on the
CVLT (Delis, Massman, Butters, & Salmon, 1991), whereas patients with HD have a relatively lower rate of intrusions on this test (Kramer et al., 1988). Other studies have also
found that analysis of perseverations and intrusions helped to better clarify the nature of
cognitive impairment in a variety of patient groups, including individuals with schizophenia (Perry & Braff, 1998), aphasia secondary to stroke (Helm-Estabrooks, Ramage, Bayles,
& Cruz, 1998), closed head injury (Hotz & Helm-Estabrooks, 1995b), and Lewy body or
Alzheimers dementia (Doubleday et al., 2002).
Despite the clinical utility of examining these error types, there have been some
inconsistencies and overlap in how these errors have been defined, as pointed out above.
Perhaps because of these issues there has been little research examining how these errors
might relate from a conceptual standpoint, or relatedly, whether the taxonomies used to
define these errors have any construct validity. The purpose of this present study was to
examine how various types of perseverations and intrusions are related in a group of
patients with primarily subcortical pathology using the definitions provided by Sandson
and Albert (1984). This taxonomy was chosen because it has emerged in the literature as
the most common method for delineating categories of perseveration. Patients with subcortical pathology were examined in this study because they often commit perseveration
and intrusion errors (Butters et al., 1998; Freedman, 1990; Fung, Morris, Leicester, Soo, &

956

K. L. Possin et al.
Table 1
Construct and operational definitions for the various error types

Construct definitions of
perseverations and intrusions
Stuck-in Set Perseveration: the
inappropriate maintenance of a current
category or framework.
Recurrent Perseveration: the unintentiononal
repetition, after cessation, of a previous
emitted response.
Continuous Perseveration: the inappropriate
repetition, without interruption, of a
current behavior.
Intrusion: the production of a response
inappropriate for the present task and all
previous tasks in the testing session.

Operational definitions of
perseverations and intrusions
- WCST perseverative responses
- CVLT wrong list responses
- Fluency intra-trial repeated words
- CVLT intra-trial repeated words
- Drawing repetition without
interruption on the DRS
graphomotor subtest
- CVLT non-list words
- Fluency non-target words

Continuous perseverations were not included in the PCA because they were scored as a dichotomous variable (presence vs. absence).

Davies, 1997; Lees & Smith, 1983; Levin, Llabre, & Weiner, 1989; Sandson & Albert,
1987). We studied three categories of perseverations and one category of intrusions using
various indices from four commonly used neuropsychological tests: the Dementia Rating
Scale (DRS; Mattis, 1988), the California Verbal Learning Test (CVLT; Delis et al.,
1987), the Wisconsin Card Sorting Test (WCST; Berg, 1948; Heaton et al., 1993), and
tests of letter (FAS) and category fluency (animals, fruits, and vegetables; AFV). The
three specific types of perseverations were stuck-in-set, recurrent, and continuous, and the
one type of intrusion examined was defined as a response inappropriate for the present
task and all previous tasks in the testing session. Construct and operational definitions of
these error types can be seen in Table 1. Principal component analysis (PCA) was used to
determine the relationships among these various measures of perseverations and intrusions. If Sandson and Alberts taxonomy provides a good account of these errors, and the
three types of perseverations are distinct, then we would expect that individual components would emerge corresponding to each of the three types of perseverations. In contrast, if the constructs measured by the three different types of perseverations overlap, we
would expect there to be a relationship among the various types of errors under study.

Method
Participants
A total of 77 patients with subcortical pathology participated in this study: 52 patients with
PD, 19 with HD, and 6 with Progressive Supranuclear Palsy (PSP). The patients were
referred from a movement disorders clinic only if they did not have a history of neurological disease (other than PD, HD, or PSP), serious psychiatric illness, or substance abuse. All
patients were diagnosed by a board-certified neurologist who specialized in movement disorders. PD patients were diagnosed based on the presence of at least two of the following

Perseverations and Intrusions

957

Table 2
Demographic characteristics and DRS total scores of the patient groups
Age

PD
HD
PSP

Education

DRS total

Male

SD

SD

SD

52
19
6

32
8
3

66.3
42.6
69.5

9.2
13.4
6.9

14.2
14.2
13.8

3.1
2.1
2.9

134.0
126.5
131.8

7.2
11.6
11.2

symptoms: (1) resting tremor, (2) rigidity, or (3) bradykinesia. All PD patients were
treated with dopaminergic agents at the time of testing. HD patients were diagnosed based
on a positive family history for the disease and the motor symptoms associated with HD.
Patients with PSP were diagnosed based on the presence of supranuclear gaze palsy and
bradykinesia, and at least three other common symptoms observed in this disease (e.g.,
dysarthria, axial rigidity, falls, etc.). Demographic and mean DRS scores for the patient
groups are presented in Table 2.
Scoring of Perseverations and Intrusions
A scoring system was developed to operationalize Sandson and Alberts (1984) definitions of perseverations, and the definition of intrusion proposed in this study.
Stuck-in-set Perseveration. This error type is the inappropriate maintenance of a current
category or framework. Two measures of stuck-in-set perseverations were included in this
study. On the WCST, this type of perseveration was scored when a participant inappropriately persisted in sorting to a category despite feedback from the experimenter that the
sorts were no longer correct. This type of error is labeled as a perseverative response in
the traditional WCST scoring system, and has previously been used to operationalize
stuck-in-set perseveration (Sandson & Albert, 1984). On the CVLT, a stuck-in-set perseveration was scored when a participant provided a List A word when they were asked to
name List B words, or vice-versa. This type of error is scored as an across-list intrusion on the CVLT-II1.
Recurrent Perseveration. This error type is the unintentional repetition, after cessation, of
a previously emitted response after an intervening response or intervening stimulus. In
contrast to a stuck-in-set perseveration, a recurrent perseveration is appropriately within
the framework of the task at hand. Hotz and Helm-Estabrooks (1995b) provided the recurrent perseveration example of a patient who is asked to repeat a list of nine words that
have just been read to him, and responds with sweater, jacket, grapes, sweater. Two
measures of recurrent perseveration were included in this study. On the CVLT, a recurrent
perseveration was scored when a participant repeated a correct response during a given
trial after at least one intervening response. This type of error closely corresponds to a
perseveration in the CVLT scoring system, and a repetition error in the CVLT-II scoring system, with the exception that repeated responses without an intervening response are
1
We also examined stuck-in-set perseverations on the Letter and Category Fluency tests and
found that only 13 participants committed these types of errors. Because of this low occurrence, stuckin-set errors from the fluency tests were not included in the analyses described below.

958

K. L. Possin et al.

also included in the traditional scoring systems. On the Letter and Category Fluency Tests,
a recurrent perseveration was scored when a participant repeated a correct response after
at least one intervening response.
Continuous Perseveration. This type of perseveration is the inappropriate repetition,
without interruption, of a current behavior. A continuous perseveration was scored on the
graphomotor subtest of the DRS when a participant clearly repeated a component of a
drawing or an entire drawing without interruption. For example, the participant may continue to draw the triangles of the ramparts drawing rather than alternating, or the participant may draw circles until the end of the page rather than just one as instructed. Because
continuous perseveration was scored as a dichotomous variable (presence versus absence
of a continuous perseveration), it was not included in the principal components analysis,
but analyzed separately for its relationship with factor scores and other neuropsychological tests.2
Intrusion. This error type was defined as a response inappropriate for the present task and
all previous tasks in the testing session. Intrusions on the CVLT were scored when words not
on a list that had been read were produced as responses. This error type is equivalent to total
intrusions on the CVLT-II, after subtracting across-list intrusions. However, because this
index was not included in the original CVLT, we computed it by hand for each participant.
Intrusions on letter and category fluency were scored when words that did not begin with the
letter or belong to the category of the present or previous fluency tasks were produced as
responses. Proper nouns and numbers on letter fluency were also scored as intrusions given
that participants were explicitly told not to provide these types of responses.
Neuropsychological Assessment
In order to identify how the error indices examined in the present article relate to performance on traditional neuropsychological test indices, we administered additional neuropsychological tests to the patients. Tests administered and indices studied included the DRS
(total score; Mattis, 1988), Digit Span subtest from the Wechsler Adult Intelligence ScaleRevised (WAIS-R; longest span achieved; Wechsler, 1981), Trails A and B (time to completion; Reitan & Wolfson, 1985), letter and category fluency (total words produced),
Digit Symbol (WAIS-R; total score), WCST (total categories achieved; Heaton et al.,
1993), Vocabulary (WAIS-R; total score), Boston Naming Test (BNT; total score;
Kaplan, Goodglass, & Weintraub, 1983), Block Design (WAIS-R; total score), Judgment
of Line Orientation (JLO; total score; Benton, Hamsher, Varney, & Spreen, 1983), Rey
Complex Figure Test (RCFT; total score on copy, immediate recall, and 20-minute delay;
Osterrieth, 1944; Rey, 1941), CVLT (total free recall of List A trials 1-5 and long delay
free recall; Delis et al., 1987), and Finger Tapping (mean taps for dominant and nondominant hands across 10, 10-second trials; Reitan & Wolfson, 1985).

Data Analysis and Results

The patients error types were scored by one of two authors (KP or VZ). In order to establish consistency in scoring, they simultaneously scored a randomly selected sample of 20
2
Continuous perseverations were also examined on the CVLT, Letter Fluency, and Category
Fluency tests and were found to occur in only 7 participants. This low number did not allow us to
include these errors from these tests in the analyses described below.

Perseverations and Intrusions

959

patient charts during a training phase. Following this training, each rater independently
scored a random sample of 15 charts for reliability analysis. Interrater reliability was adequate (r=.95). Given this high interrater reliabilty, the remaining 42 charts were each
scored by one rater. Prior to analysis, the scores on the two measures of stuck-in-set perseverations (CVLT wrong list words and WCST perseverative responses), two measures of
recurrent perseverations (CVLT intra-trial repeated words and Fluency intra-trial repeated
words) and two measures of intrusions (CVLT non-list words and Fluency non-target
words) were converted to ratio scores by dividing the total number of a given error type by
the total number of responses given on that specific measure. The conversion to ratio
scores was carried out because it was possible that the absolute number of errors would
not adequately reflect the propensity of a participant to commit such an error given the
total number of responses provided. For example, 3 perseverations reflects a higher propensity to commit these types of errors relative to 10 total responses (ratio score = .3) than
relative to 30 total responses (ratio score = .1). Therefore, ratio scores were used in the
analyses described below. The means, medians, minimums, maximums, and standard
deviations of the ratio scores, as well as the proportion of participants who attained scores
of 0 on each measure, are presented in Table 3.
The distributions of data collected on these six error ratio scores were examined to
determine whether they met the assumptions of multivariate analysis. Univariate outliers
were identified using a z-score cut-off of 3.29 (p<.001) and visual analysis of histograms
for scores unattached to the rest of their distribution (as suggested by Tabachnick & Fidell,
2001). Two CVLT intrusion univariate outliers were identified with z-scores of 3.4 and
3.2. These scores were winsorized to one point higher than the next highest score, modifying their z-score values to 2.26. One CVLT Recurrent Perseveration univariate outlier was
identified with a z-score of 3.4. This score was winsorized, modifying its z-score value to
2.07. Three WCST Perseverative Response scores were identified as univariate outliers
with z-scores of 3.76, 3.00, and 2.97. Although the latter two scores did not exceed our
z-score cutoff of 3.29, they exceeded the next highest score by .85 standard deviation units
and contributed to a highly significant positive skew. These scores were winsorized, modifying their z-score values to 2.14.

Table 3
Descriptive statistics for perseveration and intrusion ratio scores and the proportion of participants who attained a score of zero on each measure
Mean

Median

SD

Min.

Max

Score = 0

Stuck in set perseverations

WCST perseverative responses
CVLT wrong list words

.19
.02

.14
.01

.12
.03

.00
.00

.51
.13

.00
.43

Recurrent perseverations
Fluency intra-trial repeated words
CVLT intra-trial repeated words

.05
.06

.04
.05

.04
.05

.00
.00

.21
.19

.16
.09

Intrusions
Fluency non-target words
CVLT non-list words

.02
.05

.01
.03

.02
.06

.00
.00

.09
.25

.43
.23

960

K. L. Possin et al.

Using a p value of .01 for skewness and kurtosis (Tabachnick & Fidell, 2001), all 6
variables had significant positive skew, and were transformed using a square root transformation. The transformation reduced positive skew in all variables; however, WCST Perseverative Responses retained a significant positive skew with a standardized score of 3.33
(p < .01). Considering that the population distribution underlying this error measure is
expected to be positively skewed, and there were no distinct outliers upon visual inspection of the distribution, the variable was maintained with the square root transformation.
All kurtosis values were not significant after the square root transformations (p > .01).
Pairwise linearity was checked using scatterplots and found to be satisfactory. Using Mahalanobis distance with p < .001 (Tabachnick & Fidell, 2001), no multivariate outliers were
identified.
Principal components extraction with varimax rotation was performed through SPSS
FACTOR on the 6 perseveration and intrusion measures for the sample of 77 patients3.
Communality values ranged from .42 to .63. All measures were maintained. The analysis
yielded a two-component solution, accounting for 54% of the variance in the observed
variables. The first component accounted for 32% of the variance; the second component
accounted for 22%.
Component loadings for each of the variables can be seen in Table 4. Variables with
loadings of .45 and above are interpreted (Comrey & Lee, 1992). The following measures,
found to load on Component 1 stuck in set perseverations and intrusions, are presented
here with their loadings: CVLT wrong list words (.76), CVLT non-list words (.71), Fluency non-target words (.65), WCST perseverative responses (.64). The following measures were found to load on Component 2 recurrent perseverations: Fluency intra-trial
repeated words (.79), CVLT intra-trial repeated words (.74). CVLT non-list words had a secondary loading on Component 2 of -.34. All other secondary loadings were less than .14.
To determine whether continuous perseverations were associated with either of the
components derived from the PCA, factor scores for each component were derived using the
regression approach in SPSS FACTOR after the principal components extraction with
varimax rotation. These scores were then correlated with the occurrence of a continuous perseveration on the graphomotor subtests of the DRS (n=26 participants who made such errors
Table 4
Factor loadings for all indices
Component 1
Stuck in set perseverations
WCST perseverative responses
CVLT wrong list responses
Recurrent perseverations
Fluency intra-trial repeated words
CVLT intra-trial repeated words
Intrusions
Fluency non-target words
CVLT non-list words
3

Component 2

.64
.76

.13
.10

.10
.10

.79
.74

.65
.71

.05
.34

Principal components extraction with direct oblimin rotation was also performed to determine
if the solution would change if the components were allowed to correlate. The measures loading on
each component did not change from those determined by varimax rotation and the correlation
between the components was negligible at -.05, so varimax rotation was chosen.

Perseverations and Intrusions

961

vs. n=51 who did not) using point-biserial correlations. The results revealed a significant
association between the presence of a continuous perseveration with Component 1, (rpb=.39,
p < .001), indicating that those patients who committed a continuous perseveration tended to
also commit more stuck-in-set perseverations and intrusions. In contrast, the presence of a
continuous perseveration was not associated with Component 2, (rpb =.11, p=.34), suggesting that recurrent perseverations were not associated with continuous perseverations.
To explore the relationship between perseverative or intrusive errors and performance
on the neuropsychological tests, Pearson product-moment correlations between factor
scores and traditional indices on the neuropsychological tests were calculated. Also, pointbiserial correlations were performed to examine the association between the presence of a
continuous perseveration and the neuropsychological test scores. Some participants did
not receive all of the neuropsychological tests, so the range of sample size varied by correlation from 68 to 77. The results of these correlations are presented in Table 5.
The stuck-in-set perseveration and intrusion component (Component 1) was significantly associated with poorer performance on the DRS, Trails A and B, FAS, AFV,
WCST categories, Vocabulary, BNT, Block Design, JLO, Digit Symbol, RCFT (copy and
immediate and delayed recall), CVLT (trials 1-5 and long delay free recall). The component
Table 5
Correlations of neuropsychological tests with factor scores and
continuous perseveration
Neuropsychological
test

F1: Stuck-in-set /
intrusion (r)

F2: Recurrent(r)

Continuous(rpb)

DRS
Digit span forward
Digit span backward
Trails A
Trails B
Letter fluency
Category fluency
Digit Symbol
WCST categories
WCST set losses
Vocabulary
BNT
Block design
JLO
RCFT copy
RCFT immediate
RCFT delay
CVLT 1-5
CVLT long delay
free recall
Finger Tapping D
Finger Tapping N

.51**
.05
.19
.30*
.34**
.31**
.48**
.40**
.61**
.20
.27*
.23*
.39**
.45**
.47**
.29*
.30*
.43**
.49**

.10
.05
.07
.03
.07
.13
.15
.07
.03
.11
.01
.05
.11
.05
.21
.19
.14
.12
.11

.47**
.11
.04
.30*
.26*
.22
.27*
.30*
.24*
.12
.30*
.18
.17
.19
.27*
.04
.08
.20
.02

.02
.01

.05
.06

*p<.05.
**p<.01.

.02
.07

962

K. L. Possin et al.

was not significantly associated with Digit Span forward and backward, WCST set losses,
or Finger Tapping. The recurrent perseveration component was not significantly associated with any test of cognitive or motor functioning administered. Presence of continuous
perseveration was significantly associated with poorer performance on the DRS, Trails A
and B, AFV, WCST categories, Vocabulary, RCFT copy, and Digit Symbol. Significant
associations were not found between continuous perseveration and Digit Span forward
and backward, letter fluency, WCST set losses, BNT, Block Design, JLO, RCFT (immediate and delayed recall), CVLT (trials 15 and long delay free recall), or motor functioning (Finger Tapping).

Discussion
The purpose of the present study was to investigate the constructs of perseveration and
intrusion in patients with subcortical pathology. Sandson and Albert (1984) differentiated
three categories of perseverations, which they argue are distinct at the levels of clinical
features, process, and neuroanatomy. This taxonomy has emerged as the most common
method for delineating types of perseveration in the literature. However, the relationship
between or independence of these categories has not been formally tested. If these types of
perseveration are distinct at the level of process and neuroanatomy, as postulated by Sandson
and Albert, we would expect across-test measures of the same error type to load together
on components derived from a PCA, and measures of different error types to load
separately.
Two components emerged from the PCA. The indices that loaded on Component 1
were the two measures of stuck-in-set perseverations (WCST perseverative responses and
CVLT wrong list words) and the two measures of intrusions (Fluency non-target words
and CVLT non-list words). The indices that loaded on Component 2 were the two measures of recurrent perseverations (Fluency intra-trial repeated words and CVLT intra-trial
repeated words). The presence of a continuous perseveration on the graphomotor subtest
of the DRS was significantly associated with higher scores on Component 1, but not Component 2. Importantly, the test indices that loaded on the different components did not
break down along specific test lines. That is, all measures from the CVLT did not load on
one component, and all measures from the Fluency tests did not load on another component. Rather, the test indices that were used to define the constructs of interest a priori
were associated with one another. These findings lend some support to the manner in
which we operationalized the constructs.
Overall, the present results provide some support for the taxonomy proposed by
Sandson and Albert (1984). Specifically, the loading of the recurrent perseveration measures on Component 2, orthogonal to Component 1, provides evidence that recurrent
perseverations are distinct from stuck-in-set perseverations, and the lack of a correlation
between Component 2 and the measure of continuous perseveration suggests that recurrent perseverations are not associated with continuous perseverations. In contrast, the
results from the PCA did not support a distinction between stuck-in-set perseverations
and continuous perseverations. Specifically, Component 1, which included measures of
stuck-in-set perseverations, was significantly associated with a measure of continuous
perseverations (i.e., continuous drawings on the graphomotor subtest of the DRS). In addition to examining the three types of perseverative errors proposed by Sandson and Albert,
we also examined whether intrusion errors were related to these three types of errors.
Interestingly, intrusion errors were significantly associated with Component 1, but
not Component 2. These findings provide further support for the separation of recurrent

Perseverations and Intrusions

963

perseverations from the other error types. Thus, taken together, the results of the PCA provide support for certain aspects of the taxonomy proposed by Sandson and Albert that
is, the distinction between recurrent perseverations and other types of perseverations.
The patterns of relationships among the two components from the PCA and various
neuropsychological tests were also revealing. Specifically, Component 1, which encompassed the stuck-in-set perseverations and intrusion errors, was associated with clinical
tests tapping a wide range of cognitive areas, including executive functions, language,
visuospatial processes, and memory. In fact, this component correlated with 16 out of the
21 indices examined from the neuropsychological battery we administered (see Table 5).
These findings suggest that stuck-in-set and intrusion errors may be a general indicator of
cognitive integrity in patients with subcortical pathology. Consistent with this possibility,
stuck-in-set perseveration has been associated with the current severity of cognitive functioning in patients with HD (Lange, Sahakian, Quinn, Marsden, & Robbins, 1995;
Lawrence et al., 1996) and has been shown to be a good predictor of future cognitive
decline in non-demented patients with PD (Woods & Troester, 2003).
Given the high rate of correlations between Component 1 and the various clinical
neuropsychological tests, it was not surprising that continuous perseverations were
also correlated with a large number of the clinical measures (see Table 5). However,
in contrast to the relationship between the neuropsychological measures and Component 1, the relationship between the clinical tests and continuous perseverations was
somewhat more specific. That is, continuous perseverations appeared to be associated
with tests of general cognitive functioning (DRS), traditional measures of executive
functioning (Trails B, AFV, WCST categories), and other measures which likely have
an executive function component (Digit Symbol, Trails A, RCFT copy). Importantly,
unlike Component 1, this error type did not correlate with measures of memory. Thus,
despite the fact that stuck-in-set perseverations, intrusion errors, and continuous perseverations are associated, and therefore likely share at least one common underlying
process, there appears to be some specificity between stuck-in-set perseverations and
continuous perseverations.
Given the findings in the present study, one important issue that arises is what might
be the underlying cognitive processes that lead to: (a) the significant associations among
stuck-in-set perseverations, continuous perseverations, and intrusions; and (b) the separation of recurrent perseverations from the other error types. One possibility is that a primary deficit in inhibition accounts for the shared variance of stuck-in-set perseverations,
continuous perseverations, and intrusions. This inhibitory deficit could manifest, respectively, as difficulty inhibiting competing previous task frameworks, a current act beyond
the time it is appropriate, or responses that were not appropriate at any time. Impairments
in inhibition have been observed in patients with subcortical pathology (Filoteo, Rilling, &
Strayer, 2002; Kensinger, Shearer, Locascio, Growdon, & Corkin, 2003) suggesting the
possibility that such a process could underlie all three of these error types4.
Given the lack of associations between recurrent perseveration and the other error
types or traditional neuropsychological test indices, it is difficult to speculate on what cognitive process may be underlying this error type. Delis and colleagues (2000) suggested
that this type of error, which they have termed repetitions, could reflect a deficit in memory. That is, a recurrent perseveration (defined by the intra-trial repetition of a recalled word)
may occur because the patient forgot that they had stated the word previously during that
4
Clearly, there are many mechanisms other than inhibition that could account for the pattern of
correlations observed in this present study. We are simply suggesting that a deficit in inhibition is
one possible account of why these error types are related.

964

K. L. Possin et al.

trial. It seems unlikely that recurrent perseveration results from a memory deficit per se in
the patient groups studied because this component was not significantly associated with
any of the general memory measures. However, it is possible that some sort of cognitive
monitoring that is not specifically evaluated by global measures of memory (e.g., remembering that you remembered), similar to what Delis and colleagues described, could be
associated with recurrent perseverations.
It is also of interest to consider the neuroanatomical underpinnings of these error types.
Because the patients in this study all have diseases that affect frontal-subcortical circuitry, it
follows that this dysfunction may lead to these errors in this patient group. Sandson and
Albert (1984) speculated that stuck-in-set perseveration is related neuroanatomically to frontal lobe damage, continuous perseveration to basal ganglia damage, and recurrent perseveration to posterior left hemisphere damage. If stuck-in-set perseveration and continuous
perseveration are indeed subserved by damage to different but highly connected brain
regions, it follows that these errors should be related at the behavioral level, while at the same
time retaining some specificity as was found in the present study. It may be that recurrent perseveration is not subserved by dysfunction of the frontal-subcortical circuits in this patient
group, which could explain the independence of this error type at the behavioral level.
A few words of caution are in order regarding the limitations of our study. First, it is
important to point out that the errors we examined were removed from their original metric to correct for the association of error probability with number of responses (use of ratio
scores) and to prepare the data to meet the assumptions of multivariate analysis (modifications of univariate outliers and square root transformations). These alterations make it difficult to discuss clinical implications in terms of the absolute number of errors a patient
makes. Further, it is unclear if the errors studied provide novel information beyond the traditional indices also derived from the same tests. However, considering that the factor
scores and the traditional indices correlated in only the low to moderate range, it appears
that they are not redundant. Future work will be required in order to determine whether the
various errors derived from the present study have any clinical utility (i.e., predicting
future cognitive decline in patients with subcortical pathology).
A second potential limitation of the study is that the use of other operational definitions of the constructs in Sandson and Alberts taxonomy could have led to different
results. However, we were careful to select items that we felt best reflected the various
types of perseverations proposed by these investigators, and the results of the PCA support
our decision for how we operationalized the constructs provided by Sandson and Albert in
that those tests that were reported to measure specific types of perseverations loaded on
the same component. Nevertheless, it will be important for future studies to examine these
constructs of perseverations using different operational definitions.
A final cautionary note regarding our findings is that although the PCA provided
some support for Sandson and Alberts taxonomy in patients with subcortical pathology,
this may not hold true for all patient groups. As a demonstration of this possibility, Delis
and colleagues (Delis, Jacobson, Bondi, Hamilton, & Salmon, 2003) found that the factor
structure of CVLT variables differed markedly in patients with Alzheimers disease,
patients with mixed neurological disease, and normal controls. In particular, these investigators found that indices of delayed recall loaded together on a separate factor from indices of immediate recall in the Alzheimers patients, whereas the measures of immediate
and delayed recall loaded on the same factor in the patients with mixed neurological disease and normal controls. These findings highlight that different factor structures can be
observed in different patient populations or in normal controls. Thus, it will be important
for future studies to examine how the various constructs examined in the present study

Perseverations and Intrusions

965

relate in other patient populations before stronger conclusions can be drawn from the
present study.
In conclusion, the findings from the present study provide some support for the taxonomy of perseverations proposed by Sandson and Albert (1984). The results of the PCA
demonstrated that recurrent perseverations are likely due to a different process than are
stuck-in-set perseverations and continuous perseverations. Correlational analyses using
the clinical neuropsychological measures demonstrated that, although stuck-in-set perseverations and continuous perseverations are related, the two error types may not be due to
the exact same processes.

References
Allison, R. S. (1966). Perseveration as a sign of diffuse and focal brain damage. I. British Medical
Journal, 2, 10271032.
Benton, A. L., Hamsher, K., de, S., Varney, N. R., & Spreen, O. (1983). Judgment of line orientation. New York: Oxford University Press.
Berg, E. A. (1948). A simple objective technique for measuring flexibility in thinking. Journal of the
International Neuropsychological Society, 2, 134140.
Butters, M. A., Goldstein, G., Allen, D. N., & Shemansky, W. J. (1998). Neuropsychological similarities and differences among Huntingtons disease, multiple sclerosis, and cortical dementia.
Archives of Clinical Neuropsychology, 13(8), 721735.
Comrey, A. L., & Lee, H. B. (1992). A first course in factor analysis (2nd ed.). Hillsdale, NJ:
Lawrence Erlbaum associates, Publishers.
Delis, D. C., Jacobson, M., Bondi, M. W., Hamilton, J. M., & Salmon, D. P. (2003). The myth of
testing construct validity using shared variance techniques with normal or mixed clinical populations. Journal of the International Neuropsychological Society, 9(6), 936946.
Delis, D. C., Kaplan, E., & Kramer, J. H. (2001). The Delis Kaplan Executive Function System. San
Antonio, TX: The Psychological Corporation.
Delis, D., Kaplan, E., Kramer, J., & Ober, B. (2000). California Verbal Learning Test-II. San Antonio,
TX: The Psychological Corporation.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (1987). California Verbal Learning Test:
Adult version manual. San Antonio, TX: The Psychological Corporation.
Delis, D. C., Massman, P. J., Butters, N., & Salmon, D. P. (1991). Profiles of demented and amnesic
patients on the California Verbal Learning Test: Implications for the assessment of memory disorders. Psychological Assessment, 3(1), 1926.
Doubleday, E. K., Snowden, J. S., Varma, A. R., & Neary, D. (2002). Qualitative performance characteristics differentiate dementia with lewy bodies and Alzheimers disease. Journal of Neurology, Neurosurgery, and Psychiatry, 72, 602607.
Filoteo, J. V., Rilling, L. M., & Strayer, D. L. (2002). Negative priming in patients with Parkinsons
disease: Evidence for a role of the striatum in inhibitory attentional processes. Neuropsychology,
16(2), 230241.
Freedman, M. (1990). Parkinsons disease. In J. L., Cummings. (Ed.), Subcortical dementia (pp.
108122). London: Oxford University Press.
Fung, V. S. C., Morris, J. G. L., Leicester, J., Soo, Y. S., & Davies, L. (1997). Clonic perseveration
following thalamofrontal disconnection: A distinctive movement disorder. Movement Disorders,
12(3), 378385.
Heaton, R. K., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (1993). Wisconsin Card Sorting
Test (WCST) manual revised and expanded. Odessa, FL: Psychological Assessment Resources.
Helm-Estabrooks, N., Ramage, A., Bayles, K. A., & Cruz, R. (1998). Perseverative behaviour in
fluent and non-fluent aphasic adults. Aphasiology, 12(78), 689698.
Hotz, G., & Helm-Estabrooks, N. (1995a). Perseveration. Part I: A review. Brain injury, 9(2),
151159.

966

K. L. Possin et al.

Hotz, G., & Helm-Estabrooks, N. (1995b). Perseveration. Part II: A study of perseveration in closedhead injury. Brain Injury, 9(2), 161172.
Kaplan, E. (1988). A process approach to neuropsychological assessment. In T., Boll, & B. K.,
Bryant (Eds.), Clinical neuropsychology and brain function: Research, measurement, and practice. Washington D.C.: American Psychological Association.
Kaplan, E. F., Goodglass, H., & Weintraub, S. (1983). The Boston Naming Test (2nd ed.). Philadelphia: Lea & Febiger.
Kensinger, E. A., Shearer, D. K., Locascio, J. J., Growdon, J. H., & Corkin, S. (2003). Working
memory in mild Alzheimers disease and early Parkinsons disease. Neuropsychology, 17(2),
230239.
Kramer, J. H., Delis, D. C., Blusewicz, M. J., Brandt, J, Ober, B. A., & Strauss, M. (1988). Verbal
memory errors in Alzheimers and Huntingtons dementias. Developmental Neuropsychology,
4(1), 115.
Kramer, J. H., Levin, B. E., Brandt, J., & Delis, D. (1989). Differentiation of Alzheimers, Huntingtons,
and Parkinsons disease patients on the basis of verbal learning characteristics. Neuropsychology, 3,
111120.
Lange, K. W., Sahakian, B. J., Quinn, N. P., Marsden, C. D., & Robbins, T. W. (1995). Comparison
of executive and visuospatial memory function in Huntingtons disease and dementia of Alzheimers
type matched for degree of dementia. Journal of Neurology, Neurosurgery, and Psychiatry, 58,
598606.
Lawrence, A. D., Sahakian, B. J., Hodges, J. R., Rosser, A. E., Lange, K. W., & Robbins, T. W. (1996).
Executive and mnemonic functions in early Huntingtons disease. Brain, 119, 16331645.
Lees, A. J., & Smith, E. (1983). Cognitive deficits in the early stages of Parkinsons disease. Brain,
106, 257270.
Levin, B. E., Llabre, M. M., & Weiner, W. J. (1989). Cognitive impairments associated with early
Parkinsons disease. Neurology, 39(4), 557561.
Lezak, M. D. (1995). Neuropsychological assessment. New York, NY: Oxford University Press.
Loewenstein, D. A., Wilkie, F., Eisdorfer, C., Guterman, A., & Berkowitz, N. (1989). An analysis of
intrusive error types in Alzheimers disease and related disorders. Developmental Neuropsychology,
5(2&3), 115126.
Luria, A. R. (1966). Higher cortical functions in man. New York: Basic Books.
Mattis, S. (1988). Dementia Rating Scale (DRS). Odessa, FL: Psychological Assessment Resources.
Neisser, A. (1895). Krankenvorstellung (Fall von asymbolie). Allgemeine Zeitschrifte fur Psychiatrie,
51, 10161021.
Osterrieth, P. A. (1944). Le test de copie dune figure complex: Contribution a letude de la perception et de la memoire. Archives de Psychologie, 30, 286356.
Perry, W., & Braff, D. L. (1998). A multimethod approach to assessing perseverations in schizophrenia patients. Schizophrenia Research, 33(12), 6978.
Reitan, R. M., & Wolfson, D. (1985). The Halstead-Reitan Neuropsychological Test Battery.
Tuscon, AZ: Neuropsychology Press.
Reitan, R. M., & Wolfson, D. (1993). The Halstead-Reitan Neuropsychological Test Battery:
Theory and clinical interpretation. Tuscon, AZ: Neuropsychology Press.
Rey, A. (1941). Lexamen psychologique dans les cas dencephalopathie traumatique. Archives de
Psychologie, 28, 286340.
Sandson, J., & Albert, M. L. (1984). Varieties of perseveration. Neuropsychologia, 22, 715732.
Sandson, J., & Albert, M. L. (1987). Perseveration in behavioral neurology. Neurology, 37, 17361741.
Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Needham Heights,
MA: Allyn & Bacon.
Walsh, K. W. (1987). Neuropsychology (2nd ed.). Edinburgh: Churchill-Livingstone.
Wechsler, D. (1955). WAIS manual. New York: the Psychological Corporation.
Wechsler, D. (1981). WAIS-R. manual. New York: the Psychological Corporation.
Woods, S. P., & Troester, A. I. (2003). Prodromal frontal / executive dysfunction predicts incident
dementia in Parkinsons Disease. Journal of the International Neuropsychological Society,9, 1, 724.