78 Titular del periódico El Diario del Otún

10.1 INTRODUCTION

The current study describes an adapted version of the Predicaments test. The aim of the study was to investigate further the contribution of interpersonal factors to real- life-type problem-solving performance. This was achieved by examining the relative performance of a group with structural anterior lesions and a matched control group on two different sorts o f problems, those containing practical problems with little interpersonal relevance, and those in which interpersonal issues were central to the problem.

The study described in chapter 7 demonstrated that anterior lesions are associated with deficits in solving interpersonal problems, and a variety o f factors was thought to contribute to this. Some of these factors were specific to understanding other people, such as pragmatic language processing, theory of mind, and empathy. Other potential factors were applicable to both interpersonal and non-interpersonal problems, such as executive deficits, and the contribution of previous experience. The non-interpersonal problems presented in the current study are expected to draw on executive processes and previous experience in a similar fashion to interpersonal problems, but the specific interpersonal factors are not expected to be relevant to performance. Thus, comparison of the patterns of performance on the two types of problem enables an assessment of the relative contributions of interpersonal factors to real-life problem-solving.

Inappropriate interpersonal behaviour is often reported to be a consequence of anterior brain lesions (e.g. Prigatano 1991a, 1991b; Bardenhagen et al, 1999; Blair & Cipolotti, 2000). People with frontal lobe dysfunction have been shown to have impairments in interpreting nonverbal cues such as facial expression and tone of voice (Homak et al.

1996; Breitenstein, Daum & Ackermann, 1998). However, contributions of factors such as these to Predicaments performance in participants with anterior lesions in the first study appeared to be slight, since there were no differences in performance when the problems were presented on video versus when they were given as stories.

However, there are other aspects of interpersonal functioning that might have been relevant to problem-solving performance in the first study. These include theory of mind, empathy, and understanding of pragmatic aspects of language. Theory of mind is the ability to appreciate other people’s mental states. Studies have shown that people with frontal lobe lesions are impaired in this ability (e.g. Channon & Crawford, 2000; Stuss et al, 2001), although there is still debate about latéralisation, and which exact areas within the frontal lobes are critical. Empathy refers to a range of cognitive and emotional processes that are involved in understanding other people, and in sharing experiences with others (Eslinger, 1998). Therefore, by definition, empathy can only be relevant to interpersonal experiences, although it may be related to be more general executive processes such as cognitive flexibility (Grattan & Eslinger, 1989). Empathy has been postulated to be dependent on frontal lobe functioning (Grattan et al, 1994; Farrow et al, 2001), and it has been suggested that there may be fractionation of empathy, with dorsolateral areas mediating cognitive empathy, and orbitofrontal areas mediating emotional empathy (Eslinger, 1998). Evidence has also implicated frontal lobe lesions in impairments in aspects of pragmatic language, such as understanding sarcasm, irony, deceit and humour (e.g. McDonald & Pearce, 1996; Bara, et al, 1997; Shammi & Stuss, 1999).

How might these processes be related to the Predicaments test? All of the situations in the Predicaments test involved an interaction between two or more people, which was related to the awkward situation. Thus, in many of them, understanding why the situation was awkward required the ability to understand the mental state of the main character, and empathise with their situation. Solutions were scored on three dimensions as to whether answers showed appreciation o f the pertinent details of the

situation, whether they were interpersonally appropriate, and whether they provided an effective practical means of solving the problem. The anterior participants showed impairment on all three aspects of functioning. Deficits in understanding and relating to other people would make if difficult to appreciate the pertinent aspects o f situations associated with interpersonal concerns. Such failures in problem appreciation could also affect participants’ selections of effective methods of solving the problems. In addition, inability to understand other people would make it more likely that participants would fail to understand that it was important to take other people’s feelings into account in their solutions, leading to solutions that were not interpersonally appropriate.

Another, less specific, source of potential difficulty with interpersonal situations would be if these were more complex than non-interpersonal problems. Thus, when it is necessary to consider more than one person’s sensibilities, and what the possible consequences of an action might be for each person, it is possible that the greater number of pertinent factors or their nature makes the situations more difficult to solve. If this is the case, then control participants, in addition to participants with anterior lesions, might be expected to gain poorer scores on the interpersonal scenarios.

The study describes the development of awkward situations in which there was a predominantly practical problem. Each scenario contained only one character, and there were no elements of interpersonal relationships to consider. Performance on these Predicaments was compared with performance on a subset of the original scenarios, in which interpersonal relationships were central to the problem. All situations were presented in story form, to avoid possible confounds o f non-verbal cues. Two groups o f participants were tested, those with structural anterior lesions, and a matched healthy control group. Following Burgess and Shallice (1996a, 1996b), the anterior participants had a unilateral lesion involving the frontal lobe, and no more than one other lobe.

10.1.1 Hypotheses

1) The main aim of the study was to examine whether there were any differences between the interpersonal and non-interpersonal items. It was anticipated that both groups might find aspects of interpersonal problem-solving more difficult than non-interpersonal problem-solving, although specific predictions were not made with respect to the performance o f the control group.

2) It was hypothesised that the anterior group would show impairment relative to the control group on aspects of both interpersonal and non-interpersonal problem­ solving.

3) It was predicted that the impairments shown by the anterior group would be more marked on the interpersonal problems than the non-interpersonal problems. This was because analysing and solving the interpersonal problems would be expected to draw on specific processes relevant to interpersonal interactions, in addition to processes such as executive function and use o f previous experience, which would be expected to be relevant to both types of stories.

10.2 METHOD

10.2.1 Participants

Thirteen participants (7m, 6f) with unilateral left-sided (n=4) or right-sided (n=9) lesions involving damage to the frontal lobes (anterior group) participated in the study. Aetiology of the lesions included vascular (n=6), head injury (n=5) and tumour (n=2). To be included in the study, participants had to be between 18 and 70 years o f age and fluent in English, with a unilateral lesion confined to one or two lobes of at least three months duration. The lesions were classified as medial, lateral or orbital using the criteria described by Damasio and Damasio (1989), and the lesion sites are shown in Table 10.1.

Table 10.1: Lesion sites for the anterior group Participant Side of lesion Size and site of iesion

1 R Large orbital, media! and lateral FL

2 R Small medial and lateral FL

3 R Small medial and large lateral FL

4 R Moderate medial and large lateral FL

5 R Large medial and lateral FL

6 R Small lateral FL

7 R Moderate lateral FL

8 R Large lateral FL

9 R Moderate medial and large lateral FL plus m oderate PL

10 L Small orbital, and m oderate lateral FL

11 L Moderate medial and lateral FL

12 L Small lateral FL plus m oderate TL

13 L Moderate lateral FL plus m oderate TL

As adequate language processing was essential for the study, participants were excluded if they had expressive or receptive dysphasia. The Test for the Reception of Grammar (TROG; Bishop, 1989) was administered as a screen for this, and participants were included who scored errors on three blocks or fewer, equivalent to adult performance at the 25th percentile or above. Exclusion criteria included other significant physical or psychiatric illness, alcohol or drug dependence, hydrocephalus and dementing conditions. Participants were also excluded if they gained an estimated premorbid verbal IQ score below 85, as measured by the NART-II (Nelson, 1991).

Twenty healthy control participants (11m, 9f) also took part in the study. The two groups did not differ significantly from each other in terms o f age (anterior mean 42.49, sd 14.99; control mean 41.35, sd 14.74), years of education (anterior mean 14.38, sd 1.89; control mean 13.70, sd 2.08), NART IQ (anterior mean 111.54, sd 9.21; control mean 112.10, sd 9.73), or TROG scores (anterior mean 78.54, sd 1.39; control mean 79.45, sd 0.69). All participants gave written informed consent for the study, and were given breaks between tasks as necessary, to avoid fatigue.

10.2.2 Experimental measure: Interpersonal and Non-interpersonal Predicaments The test consisted of eight stories of everyday awkward situations or ‘Predicaments’. The aim was to have four stories in which interpersonal issues were central to the problem, and four in which interpersonal issues were not necessarily relevant. The four interpersonal items were chosen from the eight interpersonal Predicaments described in the previous chapters. All of the original Predicaments necessarily involved interpersonal contact as they had videotaped versions containing more than one person. However, the four items that were selected for the present study were chosen because interpersonal issues, involving understanding of others’ perspectives, were central to comprehending and solving the awkward situations in each. The four stories contained problems featuring different types of interpersonal relationships, including friends, neighbours, work colleagues and relatives. An example o f a interpersonal Predicament is outlined below.

10.2.2.1 Example of a Interpersonal Predicament: Antibiotics

“Neville has gone to the pub at lunchtime for a drink with some o f his friends. They ask him why he is not drinking alcohol, and he replies that he cannot because he is on a course of antibiotics. They tell him that he will have to have a drink when Guy gets back, to celebrate Guy's new job after being unemployed for a year. Guy arrives at the table carrying champagne glasses. He has ordered champagne for all of them. All of Neville's friends try to persuade him that he should drink a glass.”

The other three items involved a dispute with some neighbours, an embarrassing situation with an employer at work, and a woman making highly personal comments to a younger relative. The set of 4 ‘interpersonal’ stories is contained in Appendix D.

For the purposes o f the current study, four further awkward situations were developed, in which there were no obvious interpersonal concerns. In order to generate the non­ interpersonal items, a large number of situations was initially generated on the basis of interviews with a range o f people of varying ages, backgrounds and ethnicity, and