Neurops.vchologia,Vol.22, No. 6, pp. 715-732, 1984.

0028-3932/84 $3.00+0.00
1984PergamonPressLtd.

Printedin Great Britain.

VARIETIES OF PERSEVERATION
JENNIFER SANDSON a n d MARTIN L. ALBERT
Department of Neurology, Boston University Medical School and Boston Veterans Administration Medical
Center, 150 South Huntington Avenue, Boston, MA 02130, U.S.A., and Department of Psychology,
Cornell University, Ithaca, NY 14850, U.S.A.

(Accepted 10 March 1984)

Abstract--We propose a new taxonomy for perseveration consisting of three categories which are
distinctive at the levels of clinical features, process, and neuroanatomy. Stuck-in-set perseveration,
the inappropriate maintenance of a current category or framework, involves an underlying process
deficit in executive functioning and is related neuroanatomically to frontal lobe damage. Recurrent
perseveration, the unintentional repetition of a previous response to a subsequent stimulus, involves
an abnormal post-facilitation of memory traces and is related neuroanatomically to posterior left
hemisphere damage. Continuous perseveration is the inappropriate prolongation or repetition of a
behavior without interruption. It involves a deficit in motor output and is most common in patients
with damage to the basal ganglia.

INTRODUCTION
THE TERMperseveration is generally used to describe any continuation or recurrence of
experience or activity without the appropriate stimulus. N~SSER [29] noted perseveration in
pathological conditions as diverse as psychosis and aphasia. He considered all forms of
perseverative behavior to be reflections of one undetermined underlying deficit.
LIEPMANN [22] provided the first classification schema for perseverative behaviors, dividing them into tonic, clonic and intentional types. A patient with tonic perseveration, as defined by Liepmann, might have difficulty releasing the hand that he had been instructed to
shake. Such a patient remains stuck, unable to relax, in the final stages of a completed action.
With clonic perseveration a patient continues to repeat the action in which he is engaged.
When asked to draw a series of three-looped figures, for example, a patient with clonic
perseveration is unable to limit his drawing to just three loops. Intentional perseveration is
the unintentional repetition of a previously emitted response when a new response is
intended. Liepmann cited as an example the patient who correctly blows out a match and
then repeats the blowing motion to subsequent stimuli. Liepmann believed both clonic and
intentional perseveration to be "ideational" in origin, "there being an impasse in the area of
sensory preparation of movement with the result that new stimuli can excite a previous idea
and the movement caused thereby" p. 572.
Subsequent taxonomies of perseveration have dropped the clonic form, considering
In the spring of 1983, a few months before his death, Henry H6caen and I discussed the important role of
perseveration in behavioral neurology and neuropsychology. We agreed that a systematic analysis of perseveration,
its influence on observed neurobehaviorai deficits and its underlying mechanisms was warranted, and that the time
was ripe for such a study. We discussed hypotheses which might serve as a framework for this new study. The
following theoretical statement, developed subsequently in Boston with Jennifer Sandson, was inspired by those
discussions--MLA.
715

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JENNIFER SANDSONand MARTIN U ALBERT

s u s t a i n e d a c t i v i t y as s e p a r a t e f r o m b e h a v i o r s o f r e p e t i t i o n , a n d m a n y h a v e c o n s i d e r e d
p e r s e v e r a t i o n t o r e p r e s e n t a u n i t a r y n e u r o p s y c h o l o g i c a l deficit. D i f f e r e n t t a x o n o m i e s
p r o p o s e d f o r p e r s e v e r a t i o n a r e p r e s e n t e d in T a b l e 1.
O u r c l i n i c a l e x p e r i e n c e , t o g e t h e r w i t h a d e t a i l e d r e v i e w o f t h e l i t e r a t u r e , r e v e a l s the n e e d
for a new system for classifying perseverative behavior. We suggest that categories within
this p r o p o s e d n e w c l a s s i f i c a t i o n s c h e m e a r e d i s t i n c t at b o t h the p h e n o m e n o l o g i c a l a n d the

Table 1. Classification schemas of perseveration

Type of perseveration

Definition

Example

LIEPMANN [22]

Tonic

inability to motoricaUy relax after

completing an action

continuing to grasp a hand after

shaking it

Clonic

continuous repetition of an action

drawing loops across an entire

page after instructions to stop
after three

Intentional

inappropriate repetition of a
previously emitted response to a
subsequent stimulus

stimulus x -. response a
stimulus y ~ response b
stimulus z -. response a

LURI^ [23]

Efferent motor

pathological inertia of a
previously emitted response

overwriting when attempting to

draw a single circle

Perseveration due to
impairment in the program of
action

defect in the program of action

inability to switch from one task,

such as drawing loops, to
another, such as alternating letters

Compulsive repetition

inappropriate repetition of a
behavior

sticking the tongue out repeatedly

instead of just once

Impairment of switching

repetition of an immediately
preceding response to the
subsequent stimulus

appropriate production of dots on

Bender Gestalt card I followed by
the inappropriate use of dots
instead of circles on card 2

Ideational

spontaneous recurrence of a
behavior after one or more
intervening stimuli

AbcdefgAhijkAIA on attempting the

alphabet

Repetitious

recurrence of all or part of a

current or previous response after
a delay

stimulus x ~ response x
stimulus b -. response x
as well as AbcdAefA on
attempting the alphabet :

Continuous

continuation of a response
beyond the point of completion
with no intervening stimuli

continuing to manipulate sticks

after completing a given design

Stuck

multiple inappropriate repetitions,

either in whole or in part, of a
previously emitted response

FREEMAN and G^~eEI~COLE[9]

HELMICK and BERG [17]

YAMADORI[38]
fu-to-ko-ro-ga-ta-ma (dagger)-fu-to-ga-ra-mi (nonsense)
on second try
fu-t o-ko-ro-ga-ta-na -,
fu-to-ga-ra-mi

717

VARIETIES OF PERSEVERATION

Table l---continued
Type of perseveration

Definition

Example

Immediate

repetition to the immediately

subsequent stimulus
either in whole or in part, of the
response to the previous stimulus

nu-ka-ni-ku-gi (a proverbt--,
nu-ka-niku-gi
ma-ke-ru-ga-ka-chi
{an unrelated proverb~--,
ma-ke-ru-ku-gioga (nonsense)

Delayed

repetition of a previously emitted

response after one or more
intervening stimuli

nu-ka-ni-ku-gi -~
nu-ka-ni-ku-gi
ma-ke-ru-ga-ka-chi --*
ma-ke-ru-ga-ka-chi
mi-ka-ra-de-ta-sa-bi
mi-ka-ra-de-ta-ku-gi

FULD et al. [10]

Perseveration

immediate recurrence of a
previously emitted response to the
subsequent stimulus

Intrusion

delayed repetition of a previously

emitted response after intervening
stimuli

no examples given

process levels, and quite possibly at the anatomical level as well. In support of this argument
we shall first present evidence for the three independent categories within the taxonomy: (1)
continuous and inappropriate repetition of a current behavior (continuous perseveration);
(2) continuous and inappropriate maintenance of a current set or framework (stuck-in-set
perseveration); and (3) unintentional repetition, after cessation, of a previously emitted
response to a subsequent stimulus (recurrent perseveration). Recurrent perseveration, in
turn, can be either immediate or delayed, depending on whether there have been intervening
stimuli between the original and perseverated responses. We shall then present evidence in
support of the three distinct neuropsychological process deficits which we believe underlie
the different clinical forms. The process deficit in recurrent perseveration involves a failure of
the usual inhibition of memory traces. In stuck-in-set perseveration it involves a breakdown
in executive functioning such that actions become dissociated from intent. In continuous
perseveration it involves a disturbance in motor output characterized by post-facilitation of
motor impulses. Neuroanatomical distinctions between subject groups exhibiting the
different syndromes will be noted throughout. Lastly, we shall present examples of each
perseverative syndrome.
EVIDENCE FOR A NEW TAXONOMY OF PERSEVERATION
Perseveration on tests requiring attention and cognitive flexibility has traditionally been
associated with frontal lobe lesions (see Table 2). This preservation, in both monkeys and
humans, is almost always of the stuck-in-set type. Adult monkeys with orbitofrontal lesions,
for example, are severely impaired on tests such as delayed alternation and object
discrimination reversal which have a large alternation component. These monkeys are not
impaired, however, on visual discrimination or delayed response tasks which require spatial
abilities or memory alone 1-12, 13, 28]. Humans with unilateral left or right frontal lobe

JENNIFER SANDSON and MARTIN L. ALBERT

718

Table 2. Perseveration after frontal lesion in monkey and human

Subjects

Relevant tasks used

Major findings

MlSHKIN [28]
Monkeys with orbital and
dorsolateral frontal lesions

delayed alteration; auditory and

visual discrimination in a go/no
go paradigm; object discrimination reversal; learning set
trials; one-trial learning; bar
pressing for reward

the orbital monkeys were

significantly more impaired than
the dorsolateral on all the tests
except delayed alternation, on
which both groups were impaired.
They were particularly impaired
on the reversal aspect of each
task. They were unable to learn to
inhibit either spontaneous or
experimenter-induced preferences.
Lesioned monkeys were slow to
extinguish bar pressing.

BUTTER 17]
Monkeys with total orbital,
posteromedial orbital, lateral
orbital, anterior orbital and
dorsolateral lesions

extinction of food rewarded

response; delayed spatial reversal;
object discrimination reversal

posteromedial and total orbital

monkeys make more perseverative
responses prior to extinction than
dorsolateral or control monkeys.
Total orbital monkeys had
significantly more perseverative
errors and perseverative error
runs than dorsolateral or anterior
orbital monkeys on object
discrimination reversal.
Dorsolateral monkeys were worse
than orbital on the spatial
reversal task, but the orbital
monkeys were also impaired.

GOLDMAN [12, 13]

Monkeys with orbital,
dorsolateral and total frontal
ablations

delayed response; delayed

alternation; visual discrimination;
object discrimination reversal

adult orbitofront al-lesioned

monkeys fail to reach criterion on
tests of delayed alternation and
object discrimination reversal, are
moderately impaired on delayed
response (although better than the
dorsolateral monkeys) and very
mildly impaired on visual
discrimination. It is concluded
that they have no difficulty with
the spatial or memory aspects of
the tasks but rather with the
reversal aspects or with
perseveration. Dorsolateral
monkeys seem to have a spatial
memory deficit, failing to obtain
criterion on delayed alternation
but not on object discrimination
reversal.

719

VARIETIES OF PERSEVERAT1ON

Table 2---continued
Subjects

Relevant tasks used

Major findings

MILNER [26, 27, 31]

Humans with unilateral
frontal and temporal lesions
for control of intractable
seizures

Wisconsin Card Sort Test;

visually guided stylus mazes;
delayed comparison

Case study of a woman with a

bilateral frontal and temporal
tumor involving the thalamus
and hypothalamus

motor and verbal tasks involving

the auditory, visual and tactile
modalities

Extensive clinical observation

of frontal lobe patients with
varying etiologies

motor tasks with and without

verbal instructions

patients with both right and left

frontal lesions were impaired on
the Wisconsin Card Sort Test.
Many patients were aware of their
deficits, stating that they knew it
was the color, the shape or the
form, while remaining unable to
alter their response strategy.
Patients with right frontal lesions
were significantly worse than
other groups at learning to follow
a stylus maze with auditory
feedback. They repeatedly broke
the rules and made the same
errors often even when corrected.
Right frontal patients were also
significantlyworse on a test of
delayed comparison (which one of
these stimuli have you seen more
recently?).

HUDSON[18]
the patient perseverated on tests
of proprioeeption and
stereognosis. Perseverations were
sometimes carried over from one
modality to another, resulting in
bizarre behavior. The patient's
drawing of a cat was particularly
notable for its incorporation of
the features of a man from the
previous assignment. Writing
showed perseveration of words
and consonants.

Lulu^ [23]
there are two distinct types of
motor perseveration.

lesions are impaired on the W i s c o n s i n C a r d Sorting Test, a task requiring c o n c e p t u a l shifting

[27]. A striking aspect of this stuck-in-set perseveration is the ability of the patient with
frontal lobe d a m a g e to verbalize that his response should be guided by color, shape or
n u m b e r while consistently sticking to only one d i m e n s i o n .
H u d s o n [18] described the stuck-in-set variety of perseveration on verbal a n d n o n - v e r b a l
tasks i n v o l v i n g the auditory, visual a n d tactile modalities in a w o m a n with massive frontal
lesions with t h a l a m i c a n d h y p o t h a l a m i c extension. T h e p a t i e n t ' s d r a w i n g of a cat was
particularly n o t a b l e for its i n c o r p o r a t i o n of the features of a m a n from the previous
assignment. Perseveration c o n t i n u e d even when m o d a l i t y of response was changed. L u r e ^
[23] reported the case of a w o m a n with a large t u m o r of the posterior frontal lobes w h o was

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JENNIFER SANDSONand MARTIN L. ALBERT

unable to perform without perseveration any series of motor actions such as drawing
alternating shapes or performing multiple movements to command. Tasks in which the
required movement differed from the examiner's signal (e.g. raise your hand when I knock)
were particularly difficult. Similar perseveration was noted in writing and in calculation and
was not improved with visual example. The patient, however, showed no evidence of
compulsive (continuous) movements and was able to stop an initiated action appropriately.
Stuck-in-set perseveration has also been observed in patients with Parkinson's disease [20]
and in dementia of undetermined etiology [9].
Perseveration is also common in aphasia, where it is seen on a variety of verbal and nonverbal tasks (see Table 3). Most perseveration in aphasia seems to be of the recurrent type.
ALLISONand HURWITZ [2], for example, found that 16 of 24 aphasic subjects perseverated
on at least one of a series of tasks, most of this perseveration consisting of repetition of a
previously emitted response to a subsequent stimulus, such as on a visual naming task.
Perseveration was also common in response to simple verbal commands, in reversing
automatic series and in spontaneous speech.
HELMICK and BERG [17] administered a variety of tasks to both right- and lefthemisphere-damaged (aphasic and non-aphasic) patients. Significantly more perseveration
was found in the language-disturbed left-hemisphere-damaged patients than in the other
groups. Perseveration followed the presentation of a subsequent stimulus 66% of the
time. MATEER[24] reported significantly more perseveration, largely delayed, in aphasics on
a task involving imitation of multiple oral movements than in right hemisphere controls.
YAMADORI[38] reported perseveration in 33 of 38 aphasic subjects on a verbal repetition
task. Again, most of the perseverations occurred after presentation of the next stimulus.
There was no correlation between perseveration and type or severity of the aphasic deficit.
BUCKINGHAMel d . [6] analyzed both spontaneous and elicited speech samples from two
patients with jargon aphasia due to posterior parietal lesions. Delayed perseverations were
found to be quite frequent and to involve single words most often. The perseverate was
sometimes a slightly altered version of the original utterance and sometimes a phonological,
lexical or semantic blend. SHINDLERel al. [34] reported that 83 ~o of Wernicke's, 5030 of
Broca's and 38 /oofanomic aphasics made at least one delayed perseverative error on a series
of three verbal tests. While continuous perseverations did occur occasionally, they were
significantly less frequent. There was no correlation between the two types of perseveration.
Recurrent perseveration is also common in patients with dementia, especially senile
dementia of the Alzheimer's type. FULD et al. [10] reported that 88~ of patients with
Alzheimer's disease and 57 9o of patients with multi-infarct dementia produced at least one
delayed perseveration on a neuropsychological battery. SHINDLER et al. [34] reported
recurrent perseveration in 55 0 of patients with Alzheimer's disease, 40 ~ with multi-infarct
dementia and 20 ~o with normal-pressure hydrocephalus.
Continuous perseveration is best exemplified by LUmA'S[23] case report of a woman with
a massive tumor involving both frontal lobes and the basal ganglia. This patient had no
difficulty switching from one activity to the next or carrying out conditioned responses to
verbal instructions. When asked to draw a circle, however, she made multiple circular
movements and was unable to stop. Similar continuations were observed with writing and
with tapping. Continuous perseveration has been reported in schizophrenia [9] and in
normal-pressure hydrocephalus [34]. It is also cited occasionally in aphasia (e.g. [17]), but
only in cases where the possibility of subcortical damage has not been definitely ruled out.
Various combinations of the perseverative syndromes are observed in many neurological
conditions. In addition, normal children under 5 yr show more perseverative behavior

721

VARIETIES OF PERSEVERATION

Table 3. Perseveration in aphasia

Subjects

Tasks used

Major findings

HALVERN [15]
33 dysphasic patients of mixed
etiology; unknown lesions

72 words presented in visual,

auditory and auditory-verbal
modality for verbalization

24 aphasic patients of mixed

etiology (16 vascular); lesion
location unspecified

tests involving chiefly nonlinguistic activities such as

searching for objects, simple
drawings and simple constructions; tests of gesture and
pantomime; tests of simple
spoken commands; repeating and
reversing the order of series;
naming sighted objects; naming
from memory; writing; reading;
spontaneous speech

stimuli in visual condition were

perseverated the most.
Perseveration correlated positively
with stimulus length in all
modalities and with abstraction in
the visual modality. There was no
correlation between perseveration
and either part of speech or
frequency.

ALLISONand HtrawiTz [2]

16/24 subjects perseverated on at
least one task. Only 5/24
perseverated on tasks involving
chiefly non-linguistic activities.
Perseveration was "'common" in
response to simple commands, in
reversing automatic series, in
naming sighted objects (when the
perseverate was often a blend of
current and previous stimuli) and
in spontaneous conversation.
Perseveration was "'uncommon"
in naming from memory, reading
and writing. Perseveration was
more "common" in the patients
with the least spontaneous speech.

HELMICKand BF~O ['17]

30 brain-damaged patients: 18
aphasic, 12 non-aphasic; 28
left hemisphere, 2 right
hemisphere; mixed etiology:
10 controls

naming and reversing series;

writing sentences and a letter;
drawing designs from memory;
drawing designs from verbal
memory; constructing designs;
naming and describing the
function of sighted objects;
describing a picture; defining
words; answering simple questions

the brain-damaged group as a

whole perseverated on 10% of all
trials. There was significantly
more perseveration in languagedisturbed than in non-languagedisturbed subjects. 66% of all
perseverates were of the
repetitious variety. 3470 of all
perseverates were continuous.
Per~everation was seen most often
on the least automatic tasks.
Perseveration was more common
on reversing series, writing
sentences and drawing designs
from memory and less common
on answering questions, defining
words and describing a picture.

MATEER [24]
20 aphasic patients: 8 nonfluent, 12 fluent; 21 nonaphasic left hemisphere
patients; 21 right hemisphere
patients; 27 controls

imitation of multiple oral

movements

Fluent aphasics and non-aphasic

patients with left hemisphere
damage made significantly more
perseverative errors than either
right hemisphere patients or
controls. 78% of perseverative
errors were of the delayed variety.
Right hemisphere patients did not
differ from controls in terms of
perseveration.

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JENNIFER SANDSONand MARTIN L. ALBERT

Table 3 - - c o n t i n u e d
Subjects

Tasks used

Major findings

YAMADORI[38]
38 aphasic patients: 24
anterior, 14 posterior; mixed
etiology

repetition of meaningful and nonmeaningful stimuli varying in

length

Jargon aphasics

neologistic responses from

collected corpora

perseveration was observed in

33/38 patients. Perseveration did
not correlate with severity,
duration or type of aphasia.
Delayed-type perseveration was
observed only in response to
meaningful stimuli.

BUCKINGHAMet al. [5]

neologisms contain more
alliteration and assonance than
would be expected by chance.

BUCKINGHAMet al. [6]

2 aphasic patients with
posterior parietal lesions

analysis of large samples of

spontaneous and elicited speech
with emphasis on delayed
repetitions

20 aphasic patients: 6
Wernicke's, 8 anomic, 6
Broca's

visual confrontation naming;

word associations; WAIS
vocabulary subtest

words were the linguistic unit

most often perseverated. The
perseverated response was not
always appropriate initially. The
perseverate was sometimes a
slightly altered version of a
previous response, sometimes a
phonological, lexical or semantic
blend and sometimes a neologism.
The perseverate frequently had a
glottal sound as if it had been cut
off.

SHINDLER et al. [34]

83 ~o of Wernicke's, 50% of
Broca's and 38 % of anomic
aphasics made at least one
perseverative error. Perseveration
correlated positively with naming.
Intrusions correlated positively
with poor hygiene and Iogorrhea
and negatively with WMS
information, idiom comprehension and WMS verbal memory.
There was no correlation between
perseverations and intrusions.

(of the stuck-in-set type) than older children [32]. Normal elderly persons on a task of word
list generation perseverate, as do normal young adults in spontaneous speech. It is
interesting, however, that perseveration is very rarely reported after focal right hemisphere
damage. See Table 4 for an overview of perseveration in the neuropsychological literature.
EXPLANATORY THEORIES OF PERSEVERATION
Many different accounts of perseveration have been proposed (see Table 5 for a
summary). None of these accounts, however, is adequate to explain all three perseverative
syndromes. GOLDSTEIN [14] claimed that perseveration was attributable to a catastrophic

VARIETIESOF PERSEVERATION

723

Table 4. Perseveration in neurology and neuropsychology (excluding reports in aphasia and focal frontal lesions)
Subjects

Tasks used

Major findings

Dementia

FREEMAN and GATHERCOLE [9]

20 demented patients; 20
schizophrenics

free conservation; Bender cards;

stick test designs; WMS designs;
body part commands; drawing;
writing, cancellation of letters;
WA1S similarities; WAIS
vocabulary; animal naming;
recitation of series; Rorschach

there was no difference in the

total number of perseverations
between the two subject groups.
The schizophrenic subjects
produced more compulsive
repetitions while the demented
subjects had a more difficult time
switching from one set to another.
There was no correlation between
the tests for any of the three types
of perseveration. The greatest
perseveration was elicited by the
Rorschach.

FULD et al. [10]

38. demented patients: 21 with
SDAT, 17 other

3-hr neuropsychologicai battery

17 healthy elderly; 20 focal

brain lesion patients; 22
patients with dementia other
than SDAT; 22 patients with
SDAT

visual confrontation; naming;

popular word associations; WAIS
vocabulary subtest

SHINDLER,et aL

88 ~o of patients with SDAT and

57~o of patients with MID made
at least one intrusion. Intrusions
were associated with low levels of
ChAT and large numbers of senile
plaques.

[34]
55% of patients with SDAT, 407,0
of patients with MID and 20}o of
patients with NPH made at least
one intrusion. Patients with NPH
produced significantly more
perseverations than the other
groups. Perseverations correlated
positively with confabulations,
easy frustration, poor hygiene,
laconic speech and hostility. They
correlated negatively with WMS
information scores and Word
Association performance. There
was no correlation between
intrusions and any other
psychometric measure.

Parkinson's Disease

LEES and SMITH [20]

30 newly diagnosed
(untreated) patients with
Parkinson's disease

Wisconsin Card Sorting Test;

Word Fluency Test

Parkinsonian patients achieved

fewer categories and made more
perseverative errors on the WCST
than controls. Parkinsonian
patients evidenced more intrusions
on the third letter of the word
fluency test.

JENNIFER SANDSON and MARTIN L. ALBERT

724

Table 4---continued
Subjects

Tasks used

Major findings

Schizophrenia
SIEGEL et al. [35]
30 schizopherenic patients: 15
hospitalized, 15 out-patient

14-min free conversation on two

topics---one affectively charged
and the other not

the same basic idea was often

reiterated with a lack of
movement in the train of thought
in both schizophrenic groups. The
hospitalized group showed a
greater degree of this form of
perseveration than the nonhospitalized group.

KorsakofJ's disease
OSCAR-BERMAN et al. [30]
12 Korsakoff patients; 15
Huntington's disease patients;
11 aphasics; 13 alcoholic
controls

delayed alternation; delayed

response; differential
reinforcement of low rates of
responding (different subjects)

Korsakoff's patients performed

poorly on both DR and DA.
unlike Huntington's patients, who
were only impaired on DA. They
seemed to have difficulty
associating the relevant stimulus
cues with reinforcement and to be
especially sensitive to interference.
On the DRL task the Korsakoff's
never learned to slow their rate of
responding. Their performance,
however, was normal when the
delay period was ended by an
auditory cue.

Palinopsia and palinacousis

KINSBOURNE and WARRING'ION [19]
the perseverated images were of
greater intensity and remained
longer than normal after-images.
In general, they conformed to the
laws that govern normal imagery.

2 patients with left hemisphere

lesions; one of the two had a
fight upper quadrananopsia

MEADOWS and MUNRO [25]

the perseverated image usually
appears in the defective
(neglected) left visual field.
Illusions of movement sometimes
occur, as do illusions of spread.
Perseverated images were both
persistent and recurrent.

3 patients with fight

occipitotemporal lesions

Autistic children
Boocnl~g [4]
21 autistic children; 21
controls matched for nonverbal ability

a two-choice task to which a third

choice was later introduced

autistic children showed less

spontaneous alternation than
controls and were less likely to
respond to a novel stimulus.

VARIETIES OF

PERSEVERATION

725

Table 4--continued
Subjects

Tasks used

Major findings

Normal children

ROSE [32]
children under 4 yr; older
children

spontaneous alternation; mazes;

probability learning

children over 4~ yr are almost

always above chance alternators.
Children under 4~ yr rarely are
(only 1 in 12 alternated at a level
above chance). There is a sharp
drop in the number of
perseverative errors made on a
maze task at age 5 yr. Younger
children maximize more on
probability learning. They don't
seem to try new hypotheses in
order to gain 100% reward.

Stutterers

SAYLES[33]
23 male stutterers; 25 control
college students

critical flicker fusion threshold

mean flicker fusion threshold was

significantly lower in stutterers.

Rats with hippocampal lesions

Review of literature on effects

of lesions

ALTMANet al. I-3]

DRL; extinction of bar pressing;
reversal tasks

Aroused rats with hippocampal

lesions tend to emit more
responses than unlesioned
controls~

Normal elderly

SHINDLERet al. 134]

Animal naming

more normal elderly subjects made

intrusions on this task than did
demented subjects.

Normal adults

GARRETT [11]
The speech errors of young adults
contain perseverations of segments,
words and phrases.

reaction to failure on difficult tasks. W h i l e fatigue a n d f r u s t r a t i o n d o seem to a g g r a v a t e

perseverative tendencies [ l-l, p e r s e v e r a t i o n is n o t a l w a y s greater on m o r e difficult items or on
items b y which subjects are m o s t t r o u b l e d . M a n y patients, in fact, are c o m p l e t e l y u n a w a r e o f
their p e r s e v e r a t i o n s , especially when they are recurrent. FREEMAN a n d GATHERCOLE [9]
report t h a t p a t i e n t s often p e r s e v e r a t e on items they successfully c o m p l e t e on later a t t e m p t s .
Relatedly, SHINDLER et al. [34,l f o u n d n o c o r r e l a t i o n between p e r s e v e r a t i o n a n d severity of
cognitive deficits in d e m e n t e d subjects.
WEPMAN [37] suggested that verbal perseverations might c o m p r i s e a significant p o r t i o n of
an a p h a s i c ' s deficit. H e p r o p o s e d that these verbal p e r s e v e r a t i o n s were explicable in terms o f
an u n d e r l y i n g d i s o r d e r o f selective a t t e n t i o n . W e p m a n ' s c l a i m is that lexical selection a n d

726

JENNIFER SANDSON and MARTIN L. ALBERT

Table 5. Theories of perseveration

Theory

[ref.]

Catastrophic reaction [14]

Increased sensitivityto interference[27]
Pathological inertia of the stimulus [23]
Inertia of the program of action 123]
Selectiveinattention [37]
Abnormal conditioning [21]
Motivational abnormality [30]
Abnormal facilitation of memory traces [6,
18, 38]
Impaired retrieval [34]
Abnormal recall of visual traces from a
visual storage buffer [36]
Post-activation of visual memory traces [25]
Disturbance in transfer of visual memory
traces to storage buffer [36]

Proposed to explain
all forms of perseverativebehavior
perseveration in frontal lobe patients
continuous repetitions
an inability to switch activities
verbal perseveration in aphasia
some verbal perseveration in aphasia
perseveration on tasks involvinga variable reinforcement
schedule in Korsakoff's patients
delayed verbal perseverations
verbal perseverationin aphasia and dementia
visual recurrence
palinopsia
visual perseveration

verbal formulation take time and that subsequent stimuli are normally inhibited, a shutter is
closed, until processing is complete. This processing, however, may be considerably slowed
in aphasics, resulting in a longer inattentive period. When a response to an unattended
stimulus is called for, the aphasic m a y produce the name of the last attended item.
There are several important problems with Wepman's account, even within the verbal
modality to which it is restricted. First, it does not explain delayed perseverations. Second, it
does not account for the fact that verbal perseverations are frequently neologistic, blends or
contextually irrelevant. Third, aphasics perseverate in spontaneous speech when they can
permit themselves sufficient processing time. Fourth, changing the modality of input or of
response sometimes reduces perseveration. If the perseveration were caused by the closing of
an attentional shutter, modality should have no effect, as the stimulus should never be
encoded. Lastly, Wepman reports verbal perseveration on tasks where subsequent stimuli
are not presented until previous stimuli have been responded to and the shutter theoretically
opened. Aside from the occurrence of verbal perseveration, Wepman offers no evidence for a
disorder of attention in aphasics who perseverate. Wepman's observation that perseveration
may constitute a significant part of the aphasic patient's deficit is, however, extremely
important.
LEICESTER et al. [21] make the observation that some, although certainly not all,
perseverative behavior may be due to prior reinforcement and some to use of irrelevant
stimulus parameters. These particular perseverations can be explained in terms of normal
behavioral principles and do not require any abnormal physiology. They offer no
explanation, though, of why their aphasic subjects were more sensitive to these factors than
controls and why there is such variability in this sensitivity.
LURIA [23] proposed different underlying mechanisms for the two types of motor
perseveration which he observed. These two types are roughly equivalent to our continuous
and stuck-in-set categories respectively. In the first type, which he called efferent

VARIETIES OF PERSEVERATION

727

perseveration, I~oth the actual program of action and the ability to switch from one program
to another remain unimpaired while a "pathological inertia of the stimulus previously
initiated" results in compulsive repetition. Although never reported by Luria, efferent
perseveration also occurs in speech (e.g. as multiple repetitions of a final sound). Luria's term
"pathological inertia" seems to refer to a disturbance in motor output caused by abnormal
post-facilitation of motor impulses.
Luria's second type of perseveration, that manifest as an inability to switch from one
action to another, was viewed as the result of inertia of the program of action itself. Luria
noted that tasks on which verbal instructions conflict with kinesthetic or visual cues are
particularly likely to result in perseveration and emphasized the role of verbal regulation in
behavioral programming [16]. This type of perseveration seems to result from a dissociation
between action and intent. It is important to point out, though, that stuck-in-set
perseveration can occur on purely verbal tasks on which, for example, a subject might be
unable to change semantic categories.
A currently popular theory in the literature on verbal perseveration is that verbal
repetitions, of the type that we are calling recurrent perseverations, are a form of involuntary
recall resulting from the uncontrolled facilitatory activity of memory traces. According to
HUDSON [18], there is an extended period of augmentation of memory traces which must be
actively inhibited. It is a failure of this inhibition which results in the involuntary recall of
previous stimuli during attempts at subsequent recall. BUCKINGHAMet al. [6] also viewed
intentional perseveration as resulting from the abnormal post-activation of memory traces.
They claimed that new stimuli somehow become confused with still active older traces during
subsequent attempts at recall. YAMADORI[38] asserted that stuck, immediate and delayed
types of perseveration (see Table 1) reflect lessening degrees of post-activation. This
interpretation is problematic, though, as delayed perseveration would require the greatest
period of augmentation. Repetitions of the type that Yamadori calls immediate should be
classified as recurrent perseverations, as they are recurrences rather than continuations and
occur as often within one context as when switching tasks. It may be that the delayed subtype
of recurrent perseveration results from abnormal recall of post-facilitated items from a
short-term memory buffer while the immediate subtype reflects a failure, also due to postfacilitation, in the transfer of items to that buffer.
The post-facilitation of memory traces has also been proposed to explain palinopsia and
palinacousis [19, 36] and can account for recurrent perseverations on purely motor tasks.
Evidence cited in support of an underlying disturbance of memory includes the frequency
with which recurrent perseveration is observed in demented patients who have impaired
memory (e.g. [34]) and a negative correlation between delayed recurrent perseverations and
choline acetyl transferase levels [10]. DRACHMAN and LEAVITT [8] noted intrusions in
normal adults administered the anti-cholinergic agent scopolamine, which is known to
impair memory.

CONCLUSION AND EXAMPLES OF THE PROPOSED VARIETIES OF

PERSEVERATION
In summary, we have demonstrated the existence of three distinct types of perseveration
and have suggested a possible neuropsychological mechanism to account for each.
Recurrent perseveration is the unintentional repetition, after cessation, of a previously

728

JENNIFERS^NDSONand MARTINL. ALBERT

emitted response to a subsequent stimulus. The underlying process seems to involve a postfacilitation of memory traces. Recurrent perseveration is most common in aphasics with left
hemisphere lesions and in cases of dementia of the Alzheimer's type. Stuck-in-set
perseveration is the inappropriate maintenance of a current category or framework. Patients
with stuck-in-set perseveration have a disturbance in executive functioning such that actions
and goals became dissociated. It is most common in patients with frontal lobe pathology.
Continuous perseveration is the inappropriate repetition, without interruption, of a current
behavior. It seems to be caused by a disturbance in motor output and is most common in
patients with subcortical involvement.
CASE REPORTS

Stuck-in-set perseveration
J.K. is a 62-yr-old right-handed male admitted to the Aphasia/Neurobehavior Unit of the
Boston Veterans Administration Hospital for evaluation of dementia. He had no significant
medical history until approximately 1 yr prior to admission, when memory problems were
first noted. Since that time he has become progressively more irritable and has developed
trouble in walking. His voice has become slurred, hypophonic and raspy. A C T scan showed
moderate diffuse cortical atrophy; EEG was unremarkable.
The patient was alert and cooperative throughout the neuropsychological evaluation.
Language functions were significantly more impaired than visuospatial. In particular,
significant difficulties were found in object naming, word list generation, oral reading and
writing. Calculation ability was severely impaired due to both computational errors and a
failure to carry. Writing numbers to dictation was also poor. Memory deficits were observed
for both remote and new verbal information. Immediate recall of non-verbal figures was
grossly accurate. Pull to the salient features of the stimulus hindered performance across
tasks.
The most striking and pervasive aspect of the neuropsychological evaluation, however,
was the degree of stuck-in-set perseveration shown. This is particularly well illustrated by the
patient's persistence in bisecting lines on the Trailmaking Test (see Fig. 1). Line bisection had
been the appropriate response for the Cancellation Test administered earlier. Stuck-in-set
perseveration was also demonstrated on Digit Span Backwards, when the patient persisted
in repeating the numbers in the presented order, as in the previous task. Other examples
included: failure to alternate the production of cursive 'm's and 'n's; failure to switch from
addition to subtraction: and failure to point to a series of objects in order, pointing instead to
each object on every trial. There were very few instances of recurrent or continuous
perseveration in this evaluation.

Continuous perset'eration
W.S. is a 69-yr-oid right-handed male admitted for evaluation of dementia secondary to
Parkinson's disease. Tremor of right upper and lower extremeties first led to diagnosis 18
months prior to admission. Treatment course has been notable for sensitivity to antiParkinsonian medications, manifested by hallucinations and paranoia. Medical history is
remarkable for Paget's disease and for an automobile accident at age 29 with possible 24-hr
loss of consciousness.
Attention was variable throughout the neuropsychological evaluation. Performance on
visuospatial tasks was extremely slow and segmented. Pull to small details occasionally

VARIETIES OF PERSEVERATION

729

x/x,/
(A)

(B)
End

@
@

@
@

CO)
FIG. I. Examples of stuck-in-set perseveration. (A) Performance on a task of line bisection; (B)
carryover of line bisection to a task of connecting numbered dots; (C) line bisection observed on
subsequent task of alternately connecting numbered and circled dots.

730

JENNIFER SANDSON and MARTIN L. ALBERT

resulted in loss of set on constructional tasks. Performance was also poor on verbal tasks
requiring abstraction or manipulation of knowledge. Spontaneous generation of words to
categories was limited. Recall of verbal passages, however, was adequate.
The most notable aspect of this evaluation was the presence of continuous perseveration.
This is best exemplified in his production of multiple loops but is also observed in drawings to
command (see Fig. 2) and the Rey-Osterrieth Complex Figure. Recurrent and stuck-in-set
perseveration were only rarely evident.

FIG. 2. Examples of continuous pcrscvcration. (A) Patient's production of three-looped figures;

(B) patient's drawing of a daisy.

Verbal recurrent perseveration

H.Z. is a 63-yr-old right-handed man who developed staphylococcal osteomyelitis of the

right clavicle 7 months prior to this evaluation. A C1-C 3 laminectomy was subsequently
necessitated by bacteremia and abscesses. The patient was quadriparetic but had started to
improve when meningitis recurred. Simultaneous with the meningitis, the patient suffered a
left hemisphere infarct with associated speech disorder and right-sided weakness. These
difficulties had just resolved when a second left hemisphere infarct resulted in their
recurrence.
Neuropsychological evaluation revealed severe impairment on both verbal and nonverbal tasks. Verbal testing was limited by very sparse output. There was also frequent pull to
irrelevant aspects of the stimulus. Impaired pencil grip and decreased graphomotor control
limited performance on constructional tasks. Contour information, however, was well
utilized. Map orientation was relatively well preserved.
In addition to his other deficits, this patient clearly exemplified recurrent perseveration in
the verbal modality. This was particularly evident on the vocabulary subtest of the WAIS
(see Table 6). Recurrent perseveration was also observed in finger naming, on the orientation
subtest of the Wechsler Memory Scale and on the Famous Faces Test. There was evidence of
echolalia throughout the evaluation.
Non-verbal recurrent persereration

Recurrent perscveration in the non-verbal modality is well demonstrated by J.S., a 51-yrold left-handed former accountant. Five years prior to admission this patient first developed

VARIETIESOF PERSEVERATION

731

Table 6. Recurrent perseveration on the vocabulary subtest of the WAIS-R in patient H.Z.
Word to be defined

Definition

Bed
Ship

lay on
lay on, no ship, bed

Winter

winter, summer, winter, no

Breakfast

breakfast, bed, bacon

signs of lethargy, right-sided weakness and mutism. Neurologic evaluation revealed a left
fronto-parieta~ infarction. Past medical history is significant for spinal surgery to alleviate
chronic neck, back and leg pain. The current admission was precipitated by pain in the right
arm and leg.
Residual expressive difficulties made verbal testing difficult. Preserved abstraction ability,
however, was demonstrated on the similarities subtest of the W A I S . Visuospatiai capacities
were mildly to moderately impaired. There was p o o r attention to detail on the picture
completion and picture arrangement subtests. Constructions were generally simplified.
Calculations were marked by c o m p u t a t i o n a l errors. M e m o r y was p o o r on tasks involving
constructions but s h o r t - t e r m recognition was within n o r m a l limits. There was little
incidental learning.
Recurrent perseveration was exhibited on stick design construction (see Fig. 3A), drawings
to c o m m a n d (see Fig. 3B) and the Benton Visual Retention Test. T h e pattern of responses on
the Raven Test of Progressive Matrices was also suggestive of recurrent perseveration, as was
performance on the Wisconsin C a r d Sorting Test.

Model

Memory

T
A

FIG. 3. Examples of recurrent perseveration in the non-verbal modality. (A) Performance on a task of
reproducing stick designs; (B) patient's drawing of a clock with recurrence of the number 7.

Acknowled#ement--We thank Drs Edith Kaplan, Hiram Brownell and Loraine Obler, and Ms Marjorie Nicholas
for advice on the development of this paper. This project is supported by funds from the Veterans Administration
Medical Research Service.

732

JENNIFERSANDSONand MARTIN L. ALBERT

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