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NeiuTjpsychology
1996, Vol. 10, No. 4,495-51)3
Verb Confrontation Naming and Word-Picture Matching
in Alzheimer's Disease
Tammy White-Devine, Murray Grossman, Keith M. Robinson,
Kris Onishi, Nadia Biassou, and Mark D'Esposito
University of Pennsylvania Medical Center
Patients with Alzheimer's disease (AD) were asked to name pictures and perform a multiplechoice word-picture matching task with verbs and nouns. AD patients were significantly more
impaired with verbs than nouns for both naming and word-picture matching, and their patterns of
semantic naming errors differed for verbs and nouns. One subgroup of AD patients was
compromised on both naming and word-picture matching consistent with a semantic memory
deficit. Naming was worse for verbs than for nouns in these patients, and they produced
significantly fewer hierarchically related semantic substitutions for verbs than for nouns. Other AD
patients without semantic memory difficulty did not demonstrate these form class-sensitive
patterns. The investigators hypothesize that form class-specific effects in AD patients' naming are
due in part to differences in processing verbs and nouns in semantic memory.
Naming difficulty is a common problem in patients with
probable Alzheimer's disease (AD; Bayles & Tomoeda, 1983;
Hodges, Salmon, & Butters, 1991; Martin & Fedio, 1983). The
basis for this deficit, however, is unclear. Some investigators
have suggested that the naming impairment is due to degraded
processing of a concept's mental representation in semantic
memory (Bayles, Tomoeda, & Trosset, 1990; Chan et al., 1993;
Chertkow, Bub, & Caplan, 1992; Hodges, Salmon, & Butters,
1992), and others have argued that the naming deficit is due to
compromised retrieval from an output lexicon (Biassou et al.,
1995; Huff, Spanier, & Protech, 1990). Verbs and nouns may
differ both with respect to processing the mental representation in semantic memory and the output lexicon in which their
names are represented, so comparisons of verb naming and
noun naming may provide considerable insight into the basis
for a naming deficit. Most naming studies in AD have been
restricted to assessments with nouns, but one study has
documented verb naming difficulty, and AD patients in fact
performed worse in naming verbs than nouns (Robinson,
Grossman, White-Devine, & D'Esposito, 1996). The purpose
of this study was to investigate the basis for this verb confrontation naming deficit in AD.
The mental representation of a word contains multiple types
of information, including its semantic attributes and phonologi-
cal shape. Most conventional approaches to naming indicate
that semantic processing of the concept underlying a word and
retrieving the appropriate phonological information both contribute to word production (Levelt, 1989). With regard to
semantic processing, verbs resemble nouns in the sense that
there are meaning postulates associated with both types of
words. We assume that this semantic information is represented in a distributed fashion (Small, Hart, Nguyen, &
Gordon, 1995; Tippett & Farah, 1994). To the extent that
naming depends on the processing of information in semantic
memory, semantic memory difficulty may interfere with naming for verbs and nouns.
Verb meaning differs from noun meaning in several important ways, however, and form class-specific naming difficulty
may emerge if a naming deficit is at the level of semantic
memory. On the one hand, the well-organized, redundant, and
strongly hierarchical matrix relations evident among nouns are
much less evident for verbs (Jackendoff, 1983; Levin, 1993;
Miller & Fellbaum, 1991). For example, hierarchical relations
associated with familiar nouns such as apple (e.g., imageableobjcct-natural kind-edible-fruit-apple-Macintosh) are typically many levels deep, whereas hierarchical relations associated with equally familiar verbs such as run (e.g., action-self
movement-run-jog) are relatively sparse and much shallower.
Network-based models of word meaning have emphasized the
contribution of redundancy in the processing of word meaning
(Small et al., 1995). From this perspective, the meaning
relations that underlie verb processing may be more susceptible to interruption because of the limited redundancy associated with verbs in semantic memory, and the strong hierarchical redundancy associated with nouns may result in relatively
more resilient semantic memory processing for nouns. To the
extent that naming difficulty depends on semantic memory
processing, greater difficulty with verb naming than noun
naming may emerge. On the other hand, verbs have a much
richer set of argument-structure properties and associated
thematic grids than nouns (Grimshaw, 1990; Jackendoff, 1978;
Williams, 1981). For example, verb semantic processing may
Tammy White-Devine, Murray Grossman, Keith M. Robinson, Kris
Onishi, Nadia Biassou, and Mark D'Esposito, Department of Neurology, University of Pennsylvania Medical Center.
This work was supported in part by funding from the United States
Public Health Service (AG09399) and the Charles A. Dana Foundation. Portions of this study were presented at the conference for
Theoretical and Experimental Neuropsychology, Montreal, Quebec,
May 1995, and the Academy of Aphasia, San Diego, California,
November 1995.
Correspondence concerning this article should be addressed to
Murray Grossman, Cognitive Neurology Section, Department of
Neurology, Hospital of the University of Pennsylvania, 3400 Spruce
Street, Philadelphia, Pennsylvania 19104-4238. Electronic mail may be
sent via the Internet to [email protected].
495
496
WHITE-DEVINE ET AL.
include thematic roles such as agent, theme, manner, and goal
that are encoded in the verb's argument structure, and the
sentence frame that is typically associated with the verb may
support verb meaning (Fisher, Gleitman, & Gleitman, 1991;
Gleitman, 1990; Shapiro & Nagel, 1995). This partial source of
word meaning may supplement semantic processing for verbs
and lead to more accurate verb naming compared with noun
naming.
Naming also requires retrieval of a word's phonological
shape. While the precise nature of lexical retrieval remains
controversial (Levelt. 1989), this complex process appears to
involve at least an organized mental search through the output
lexicon for the target word and its abstract phonological
representation. Because a word must be retrieved as part of
the naming process regardless of its form class, a naming
deficit due lo a retrieval impairment may interfere equally with
verb naming and noun naming. However, there is some
evidence to support the claim that nouns and verbs are
associated with different output lexicons. Several patients with
focal brain insult have been described with selective difficulty
restricted to the retrieval of nouns or verbs (Caramazza &
Hillis, 1991; Damasio & Tranel, 1993; Hillis & Caramazza,
1991; McCarthy & Warrington, 1985; Miceli, Silveri, Villa, &
Caramazza, 1984; Miceli, Silveri, Noccntini, & Caramazza,
1988; Zingeser & Berndt, 1990). These findings suggest the
possibility that insult to a form class-specific output lexicon
may result in a pattern of relative naming impairment due to
difficulty retrieving nouns or verbs.
Previous studies of AD patients allow us to develop predictions regarding their relative accuracy at naming with verbs
and nouns and to begin investigating the basis for differences
between these major form classes. Assessments of naming in
AD have focused almost exclusively on the appreciation of
nouns. Evidence for a naming deficit due to impaired understanding of noun meaning has come from the observation of
semantic substitutions, including the frequent substitution of
superordinates on picture naming tasks and on semantically
guided category naming fluency measures (Bayles & Tomoeda,
1983; Bayles et al., 1990; Hodges et al., 1992; Martin & Fedio,
1983; Mickanin, Grossman, Onishi, Auriacombe, & Clark,
1994). This suggests that AD patients may be able to take
advantage of the hierarchically redundant properties of noun
matrix organization in semantic memory to compensate in part
for a meaning-based naming deficit. Additional evidence that
naming difficulty in AD is not easily attributable to a lexical
retrieval impairment is said to come from the observation of
difficulty on measures of multiple-choice word-picture matching (Huff, Corkin, & Growdon, 1986; Huff et al., 1990; Martin
& Fedio, 1983), category membership judgments (Grossman,
D'Esposito, et al., 1996), recognition of perceptual and functional associates of nouns (Chertkow & Bub, 1990b; Grober,
Buschke, Kawas, & Fuld, 1985), and anomaly judgments of
pictures and simple, subject-predicate sentences (Chertkow &
Bub, 1990a; Grossman & Mickanin, 1994; Grossman, Mickanin, Robinson, & D'Esposito, 1996).
Several studies have begun to demonstrate verb comprehension impairments in AD as well. One study found that AD
patients are more impaired than controls in their judgments of
verb meaning on a triadic comparison task (Grossman, Hughes,
Mickanin, Carvell, & D'Esposito, 1996). Another report described difficulty learning about the meaning of a new verb
(Grossman, Mickanin, Onishi, Robinson, & D'Esposito, in
press). Both of these studies also appeared to show a partial
dissociation between semantic and grammatical aspects of
verbs. For example, the acquisition of semantic meaning and
thematic role information about a new verb was impaired in
AD compared with relatively preserved information about
grammatical form class. There was no correlation between
verb confrontation naming and sentence comprehension in a
previous study of verb naming (Robinson et al., 1996). ft is thus
less likely that AD patients can use information such as the
argument structure or sentence frame associated with a verb to
compensate for verb naming difficulty.
Naming difficulty in AD also has been attributed to compromised lexical retrieval (Biassou et al., 1995; Huffet al., 1990).
This has been evident in previous studies of nouns in AD
patients by their relative confrontation naming difficulty in
comparison with their word-picture matching performance
(Martin & Fedio, 1983). Additional support for a lexical
retrieval deficit in AD has come from detailed studies of
speech errors (Biassou et al., 1995), and the results of several
priming studies indicate that AD patients are able to process
semantic associations in an automatic setting (Nebes, Martin,
& Horn, 1984; Ober & Shenaut, 1988; Ober, Shenaut, Jagust,
& Stillman, 1991). However, the earlier study of verb and noun
confrontation naming (Robinson et al., 1996) did not find a
selective correlation between a measure of lexical retrieval
(phonemic fluency) and naming accuracy with verbs or nouns.
An assessment of spontaneous speech in AD demonstrated
little difference in retrieving verbs or nouns (Blanken, Dittman, Haas, & Wallesch, 1987). These findings suggest that the
retrieval component of AD patients' naming deficit does not
selectively interfere with nouns or verbs.
In the present study, we administered a confrontation
naming task for verbs and nouns to AD patients. We expected
to confirm our previous finding that verb naming is relatively
more difficult than noun naming for AD patients (Robinson et
al., 1996). To assess the relative roles of semantic processing
and lexical retrieval in AD patients' difficulty naming with
verbs, we adopted three approaches. First, we administered a
multiple-choice word-picture matching task for verbs and
nouns. Difficulty on both confrontation naming and wordpicture matching tasks was likely to be associated with a
semantic memory impairment, and greater difficulty for verbs
than nouns on both of these tasks would be consistent with the
view that verb naming difficulty is due in part to differences in
processing the semantic representation of verbs and nouns.
Alternatively, relatively compromised confrontation naming
compared with word-picture matching would be most consistent with the view that AD patients have a lexical retrieval
impairment, and differences between verbs and nouns would
suggest impairment of a form class-specific output lexicon.
A second approach involved analyses of the semantically
related naming errors and the nature of the misnamed verbs in
AD. Thus, the role of verb and noun matrix organization in
semantic memory was assessed by determining the relative
frequency of semantically related hierarchical substitutions for
verbs and nouns. A deficit associated with differences in
497
VERB NAMING DEFICITS IN ALZHEIMER'S DISEASE
Table 1
Clinical and Demographic Features of Participants and Correlations Between Alzheimer's
Patients' Clinical Features and Their Naming With Verbs and Naming With Nouns
Clinical features
Alzheimer 's
Control
Correlations with
Alzheimer's naming
Feature
M
SD
M
SD
Verbs
Nouns
Age (years)
Education (years)
Disease duration (months)
Disease severity (MMSE)
75.21
15.57
7.12
1.65
29.00
1.25
72.05
14.62
27.00
18.52
7.29
3.04
22.32
5.66
.163
.021
.152
.145
.160
.068
.132
.171
Note.
MMSE = Mini-Mental State Examination.
processing verbs compared with nouns in semantic memory
was expected to result in many fewer superordinate semantic
substitutions for verbs than nouns. To test the hypothesis that
differences in verb and noun naming are due in part to the
other information associated with verbs, we manipulated the
number of sentence frames associated with the verb stimuli. To
the extent that this factor is a component of verb meaning that
is compromised in AD patients with semantic memory difficulty, we could expect a little difference in naming verbs with
fewer or more associated sentence frames.
Our third approach to understanding the basis for verb
naming difficulty in AD involved analyses of individual patient
performance profiles. AD is a heterogeneous disorder that
may affect lexical retrieval in some patients and semantic
memory in others. Group studies arc more effective at defining
dominant trends within a larger population because groupwide
differences reflect performance consistency and average out
spurious effects across the group. Group studies nevertheless
can be misleading if the results merely reflect an averaging
across several subgroups, as may be the case in AD. Individual
performance profiles thus should be analyzed to clarify the
nature of the naming deficit in AD. Specifically, we attempted
to identify subgroups of AD patients on the basis of their
individual confrontation naming and word-picture matching
profiles. We partitioned patients into subgroups based on the
assumption that significant impairments on both confrontation
naming and word-picture matching were more likely to be
associated with compromised semantic memory processing
compared with difficulty restricted to confrontation naming or
relatively preserved performance on both tasks. We then
they could read single words. Exclusionary criteria included the
presence of other neurodegenerative conditions such as Parkinsonian,
frontal, vascular, or metabolic dementias; a history or diagnosis of
other neurological diseases such as stroke or hydrocephalus; a primary
psychiatric diagnosis such as depression or schizophrenia; the presence of medications such as antidepressants or benzodiazepines at the
time of testing; or a metabolic or systemic disorder that might
influence cognitive performance. Each AD patient participated in all
aspects of the study described below to maintain a complete withinpatient design, but we also compared AD patient performance to 14
age-matched, «(33) = 1.27, ns, and education-matched, f(33) = 1.07,
ns, right-handed, native English-speaking control participants to place
AD patient performance in context. The control participants were
spouses or volunteers from the same communities as the AD patients.
Clinical and demographic features of AD patients and control participants are summarized in Table 1.
Materials
The participants were evaluated with line drawings depicting 20
familiar actions and 20 familiar objects labeled by 20 frequencymatched nouns and verbs, *(38) = 1.96; ns, according to form
class-sensitive norms (Francis & Kucera, 1982). The line drawings
were taken from published tests of object naming (Kaplan, Goodglass,
& Weintraub, 1983) and action naming (Obler & Albert, 1982) and
corresponded to the stimulus words listed in Table 2. The pictures of
objects and actions were judged to be of equal visual complexity during
pilot testing. The nouns were equally divided between natural kinds
(n = 10) and manufactured artifacts (n = 10). All of the verbs named
actions and were nearly equally divided between verbs that do not
typically take a direct object (« = 9) and thus are usually associated
only with two sentence frames (with or without a prepositional phrase)
and verbs that may also take a direct object (n = 11) and thus are
investigated verb and noun naming patterns in these AD
patient subgroups in greater detail.
Table 2
Method
Target Noun Names for Objects and Verb Names for Actions
Used as Stimuli
Participants
Nouns
Twenty-one right-handed, native-English-speaking patients with
probable Alzheimer's disease were recruited for participation in this
study. They were diagnosed according to NINCDS-ADRDA criteria
(McKhann et al., 1984) by experienced neurologists in the Cognitive
Neurology Clinic at the Hospital of the University of Pennsylvania. All
patients were mildly or moderately impaired according to the clinical
evaluation and an independent measure of overall dementia severity,
the Mini-Mental State Examination (MMSE) score (Folstein, Folstein, & McHugh, 1975). They did not have visual difficulties that
would have prevented them from interpreting the target pictures, and
carrot
strawberry
alligator
envelope
potato
umbrella
cigarette
elephant
kite
balloon
Verbs
ladder
pineapple
refrigerator
rabbit
doll
camel
bow
turtle
trumpet
skunk
eating
fishing
saluting
brushing
ironing
skiing
swinging
fencing
dripping
weightlifting
painting
milking
peeling
pointing
sailing
boxing
kneeling
knighting
knitting
erupting
498
WH1TE-DEVINE ET AL.
typically associated with four sentence frames (± direct object crossed
with ± prepositional phrase).
One testing condition involved confrontation naming of object
pictures with nouns and action pictures with verbs. We administered
this condition before the word-picture matching condition in all
patients to avoid giving patients the name associated with a picture
prior to their attempt to retrieve the name spontaneously. The stimuli
were presented in a fashion blocked by major form class. The order of
presentation of nouns and verbs was random, with half of the subjects
exposed to each major form class first. We tabulated the number of
correctly named pictures. An error analysis was performed on misnamed pictures, analyzing specifically for the number of semantically
related errors (responses overlapping in meaning with the target),
phonemic errors (responses overlapping in phonologic shape with the
target), circumlocutory or descriptive errors (narrative responses
describing a perceptual or functional feature of the target), and other
or unrelated errors (all other incorrect responses). The semantic
substitutions were further decomposed into superordinate errors and
contrast coordinate errors that art: at the same hierarchical level as the
target, Responses were tape recorded, and two raters (White-Devine
and Robinson) evaluated all protocols independently. They agreed on
97% of their scoring judgments. Disagreements were resolved through
consensus discussion.
Another testing condition involved a multiple-choice, word-picture
matching procedure. Thus, 20 object-noun sets and 20 action-verb
sets were presented in a picture-lo-word matching paradigm, where a
picture of an action or an object was matched to 1 of 4 written word
choices; and a word-to-picture matching paradigm, where a written
name of an action or an object was matched to 1 of 4 picture choices.
We presented the word choices in writing rather than orally to
minimize the burden of such a multiple-choice format on AD patients'
memory limitations. After confirming that there were no statistical
differences between the word-to-picture and picture-to-word conditions, these were combined for the purpose of the analyses reported
below. The four choices available for each target included the correct
item, a semantically related foil (an item from the same semantic
domain that did not have a shape in common with the correct item), a
perceptually or phonemically related foil (a picture containing a major
element with a shape that resembled the shape of the target or a word
resembling the sound of the target name, although the foil was not
semantically related to the target), and an unrelated foil (an item with
neither a semantic relationship nor a perceptual or phonemic relationship to the target). Control subjects were consistently accurate at
identifying the semantic, perceptual-phonemic, and unrelated nature
of these foils during pilot testing. The number of correct responses was
tabulated and an error analysis performed for the incorrect judgments.
Word-to-picture and picture-to-word matching conditions were presented in a blocked fashion, and noun items and verb items were
blocked within each matching condition. The 4 word-picture matching
tasks were presented in a random order across participants, with 25%
of the participants exposed to each set of items first. Other tasks were
administered between the confrontation naming and word-picture
matching tasks administered on the same day in 10 patients, and
confrontation naming and word-picture matching were presented in
separate testing sessions separated by 2-4 weeks in the remaining AD
patients.
as analysis of variance, ( test, and product-moment correlation.
Discriminant analyses (Dixon, 1988) were used to identify subgroups
of AD patients with specific patterns of relative difficulty on confrontation naming and word-picture matching. The discriminant analysis
algorithm divided the entire population, including control participants
and AD patients, into two groups based on their performance for a
particular variable of interest. A discriminant analysis must have been
significant at least at the F = 4.00 level to be considered valid. In
practice, one group identified by the discriminant analysis included the
overwhelming majority of controls, and this was considered to be the
relatively "intact" subgroup for a task. We then examined the
distribution of individual AD patients. We noted whether they were
grouped with control subjects and thus were considered relatively
intact in their performance on a task, or were grouped separately from
control subjects and thus were considered to be relatively impaired in
their performance.
Results
Group Analyses
A Friedman ANOVA by ranks compared the overall ability
to name nouns and verbs correctly across conditions in AD
patients and control participants with a Condition (confrontation naming, word-picture matching) x Form Class (noun,
verb) design. This demonstrated a significant effect, F(3) =
72.97,p < .0001. Additional analyses with the Mann-Whitney
U test revealed that AD patients perform worse than control
subjects on confrontation naming, £7(1) = 225.0, p < .0001,
and word-picture matching, £7(1) = 205.0, p < .001. Planned
within-group comparisons demonstrated that AD patients do
worse at confrontation naming than their own word-picture
matching, /(19) = 3.95, p < .001. These findings are summarized in Figure 1.
Additional analyses were performed to determine whether
AD patients are equally impaired at naming with nouns and
verbs. We found that AD patients are less accurate than
controls on confrontation naming with nouns, U(l) = 250.0,
p < .0001, and confrontation namingwithverbs, t/(l) = 285.0,
p < .00001. Moreover, planned wilhin-group comparisons
demonstrated that AD patients do worse at confrontation
naming with verbs than their own confrontation naming with
nouns, ?(19) = 2.06,p < .05. This pattern of relative difficulty
naming with verbs compared with nouns was evident in 75% of
AD patients with nonzero differences in their noun- and
verb-naming performance. Neither verb naming nor noun
naming correlated with AD patients' demographic features or
overall dementia severity, as summarized in Table 1. These
findings suggest that the confrontation naming deficit in AD is
relatively pronounced for verbs compared to their own naming
with nouns.
Analyses of confrontation naming error patterns indicated
that AD patients make significantly more semantically related
errors, t/(l) = 52.5, p < .002; descriptive errors, £7(1) = 28.5,
p < .0001; and unrelated errors, C7(l) = 40.0, p < .0001,
Statistical Analyses
Because of the ceiling effect in control participants' performance,
nonparametric statistics such as Friedman's analysis of variance
(ANOVA) by ranks and the Mann-Whitney U test were performed to
compare groups of AD patients and control subjects. Within-group
analyses in AD were performed with parametric statistical tests such
compared with control subjects. Planned within-group analyses demonstrated that AD patients produce significantly more
semantic, descriptive, and unrelated errors than phonemic
errors according to / tests significant at least at the p < .05
level. This pattern of errors was similar for verbs and nouns, as
summarized in Table 3. Despite the generally similar proper-
499
VERB NAMING DEFICITS IN ALZHEIMER'S DISEASE
verbs
WORD-PICTURE MATCHING
verbs
nouns
CONFRONTATION NAMING
Figure 1. Mean (±SD) accuracy with verbs and nouns on confrontalion naming and word-picture
matching tasks in Alzheimer's disease and control participants.
tions of semantic errors across verbs and nouns in AD, more
detailed analyses revealed different types of semantically
related errors for verbs and nouns. AD patients produced
significantly fewer superordinate substitutions during their
confrontation naming with verbs (4% of semantic substitutions) than nouns (21% of semantic substitutions), ((20) =
2.09, p < .05, although AD patients did not differ in the
frequency with which they produced other types of semantic
errors: basic level, same semantic category, r(20) = 0.58, ns,
and basic level, related semantic category, '(20) = 1.27, ns.
We also examined whether the grammatical properties of
the verbs influenced confrontation naming accuracy by comparing the verbs associated with a narrower variety of sentence
frames and the verbs associated with a wider variety of
sentence frames. However, we did not find that accuracy
naming verbs associated with more sentence frames
(57% ±31% correct) differs from naming verbs associated
with fewer sentence frames, 51% ± 41% correct. t(20) = 1.37,
ns. It is also noteworthy that accuracy of naming objects that
procedure revealed significantly worse performance in AD
patients than control subjects for word-picture matching with
nouns, [/(I) = 180.5,p < .03, and with verbs, V(l} - 223.5,
p < .0001, as summarized in Figure 1. Moreover, planned
within-group analyses demonstrated that AD patients' wordpicture matching with verbs is less accurate than their own
word-picture matching with nouns at a level that approached
significance, t(20) = 2.03, p < .059. This pattern of relative
difficulty for word-picture matching with verbs compared with
nouns was evident in 71% of AD patients with nonzero
differences in their performance with verbs and nouns. Thus,
AD patients' word-picture matching paralleled their confrontation naming, revealing a greater impairment with verbs than
with nouns on both measures.
We also examined error patterns during AD patients'
word-picture matching. As summarized in Table 4, withingroup comparisons revealed that AD patients choose semantically related foils significantly more often than perceptual/
phonemic foils, ((19) = 2.97, p < .009, and choose unrelated
are natural kinds (65% ± 35% correct) did not differ from
foils significantly more often than perceptual/phonemic foils,
accuracy of naming objects that arc manufactured, 58% ±
33% correct, t(20) = 1.48, ns.
;(19) = 3.69, p < .002. These findings indicate that semantic
Analyses of performance on the word-picture matching
AD for both confrontation naming and word-picture matching.
errors are more common than phonemic/perceptual errors in
Table 3
Percentage of Responses on the Confrontation Naming Task
Table 4
That Are Semantic, Phonemic, Descriptive, or Other Types
Percentage of Responses on the Word-Picture Matching Task
of Errors for Verbs and Nouns in Alzheimer's Disease
Semantic
Phonemic
Descriptive
Other
Target
M
SD
M
SD
M
SD
M
SD
Verb
Noun
26.6
28.1
31.4
0.0
0.8
0.0
4.4
51.7
36.5
65.2
43.2
21.7
25.2
45.7
33.6
37.3
Note. These data do not include trials where the patient did not
produce a response within the allotted time.
That Are Semantic Perceptual/Phonemic, or Other Types
of Errors for Verbs and Nouns in Alzheimer's Disease
Semantic
Perceptual/phonemic
Other
Target
M
SD
M
SD
M
SD
Verb
Noun
26.3
35.2
41.6
41.4
13.5
12.9
16.5
17.3
61.1
51.9
40.6
43.1
500
WHITE-DEVINE ET AL.
Table 5
Percentage Correct Confrontation Naming of Verbs and Nouns
by Alzheimer's Disease Patient Subgroups
Confrontation naming
Nouns
Verbs
Word-picture match
Nouns
Verbs
AD subgroup profile
MMSE
M
SD
M
50
M
SD
M
SO
Semantically preserved (n = 9)
Semantically impaired (n = 12)
21.00
14.67
87.50
41.25
15.4
21.6
85.00
30.85
10.5
18.9
92.50
79.17
3.3
13.4
91.03
73.12
5.4
14.0
Note. Patients with intact performance were clustered with controls during a discriminant analysis of
performance on the corresponding task. Patients with impaired performance were not grouped with
controls during a discriminant analysis on the corresponding task. All discriminant analyses were
significant at least at the F = 4.00 level. MMSE = Mini-Mental State Examination.
Subgroup Analyses
We sought to identify the subgroup of AD patients most
likely to have a semantic memory impairment, that is, patients
with difficulty on both the confrontation naming measure and
the word-picture matching task. Separate discriminant analyses were performed for overall confrontation naming accuracy
and for overall word-picture matching accuracy. Two subgroups of AD patients were identified with this method:
patients impaired on both confrontation naming and wordpicture matching who were more likely to have a semantic
memory impairment (n = 12), and patients without a semantic
memory impairment, including patients impaired only on
confrontation naming (n = 3) and patients with relatively
preserved confrontation naming and word-picture matching
(n = 6). These subgroups are summarized in Table 5. These
subgroups did not differ in age, F (1,20) = 0.18, ns; education,
F(l, 20) = 0.19, ns; or disease duration, F(l, 20) = 0.83, ns.
However, the subgroups differed in their overall dementia severity
as measured by the MMSE, F(l, 20) = lL82,p < .003. This
difference was due to the lower MMSE score among AD patients
with impaired confrontation naming and word-picture matching
performance in comparison with the remaining AD patients.
The AD patient subgroups differed in their confrontation
naming, ^(19) = 29.12, p < .001. An analysis of covariancc
(ANCOVA), covarying for MMSE, demonstrated that the
discrepancy in the MMSE score could not fully account for
subgroup differences in naming, F( 18) = 11.19,p < .004. Nine
of 11 (82%) Semantically impaired AD patients with nonzero
differences had more difficulty in their confrontation naming
with verbs than confrontation namingwith nouns, significant at
p < .05, according to the binomial test. As summarized in
Table 5, this difference between verb-naming accuracy and
noun-naming accuracy approached significance according to
the Wilcoxon matched-pairs signed-ranks test (z = -1.86,
p < .06). This form class effect was not evident in the subgroup
of Semantically preserved AD patients. The Semantically
impaired AD patients did not differ from the Semantically
preserved subgroup of AD patients in the overall frequency of
their semantic errors. However, more detailed analyses of the
different types of semantic errors produced during naming
revealed significantly fewer superordinate semantic substitution errors for verbs than for nouns only in the Semantically
impaired subgroup of AD patients, t(ll) = 3.55, p < .005, as
summarized in Table 6. This form class effect was not evident
in the AD subgroup with relatively preserved semantic memory.
The Semantically impaired AD subgroup also differed significantly from the Semantically preserved AD subgroup in their
word-picture matching, F(l, 19) = 11.35, p < .003. An
ANCOVA covarying for MMSE demonstrated that the discrepancy in the MMSE score could not fully account for the
difference between subgroups in word-picture matching, F (1,
18) = 3.32, 18, p < .05. Eight of the 11 AD patients with
nonzero differences had more difficulty with verb wordpicture matching than noun word-picture matching, significant atp < .05, according to the binomial test. In summary, the
subgroup of AD patients likely to have compromised semantic
memory appeared to have disproportionate difficulty with
verbs compared with nouns on both confrontation naming and
word-picture matching tasks, and this was associated with
their production of superordinate semantic substitution errors
only during noun naming but not verb naming.
Discussion
In the present study, we sought to evaluate the basis for
verb-naming difficulty in AD by performing groupwide and
individual patient assessments of confrontation naming and
word-picture matching with verbs and nouns. We found that
AD patients as a group are more compromised in their
confrontation naming than their word-picture matching, suggesting that lexical retrieval limitations contribute to the
naming deficit of AD patients. AD patients also were impaired
in their word-picture matching compared with controls. This
suggests that semantic memory limitations also play a role in
AD patients' naming difficulty. AD patients as a group were
Table 6
Percentage of Semantic Substitution Errors That Are
Superordinate During Confrontation Naming of Verbs
and Nouns by Alzheimer's Disease Patient Subgroups
Superordinate
substitution errors
Verb
Noun
AD subgroup profile
M
SD
M
SD
Semantically preserved (n = 9)
Semantically impaired {« = 12)
16.5
0.0
8.0
0.0
14.2
25.1
28.2
16.9
VERB NAMING DEFICITS IN ALZHEIMER'S DISEASE
501
more impaired in their naming and word-picture matching
with verbs than nouns. Evidence that this form class difference
is related to the processing of meaning came from three
pattern of impaired naming in a subgroup of AD patients likely
to have semantic memory difficulty provides additional support
for the claim that verb-naming difficulty in AD is due in part to
sources: AD patients had greater difficulty with verbs than
nouns for both confrontation naming and word-picture matching, AD patients had a different pattern of semantic substitution errors for verbs and nouns, and individual patient analyses
a semantic processing deficit.
Although these findings associate form-class specific naming
patterns with semantic processing deficits in AD, our observations do not fully clarify the basis for this semantic deficit. At
indicated that only the subgroup of AD patients likely to have
a semantic memory impairment were more compromised with
verbs than nouns. On the basis of these observations, we
hypothesize that the verb-naming impairment in AD is due in
least three possible accounts can explain the greater difficulty
with verbs than nouns: The first is concerned with the mental
representation of verbs and nouns in semantic memory. It has
been suggested that verbs have a much sparser and less
part to impaired semantic processing.
It is well known that AD patients have a naming impairment
and this impairment has frequently been attributed in part to a
redundant hierarchical organization than nouns in semantic
memory (Jackendoff, 1983; Levin, 1993; Miller & Fellbaum,
1991). The highly structured and redundant organization of
deficit in processing semantic memory. One source of evidence
concerning the semantic basis for naming difficulty in AD
includes reports of impaired performance on tasks that do not
matrix relations for nouns may explain in part the frequent
finding that AD patients name objects with superordinate
terms even if they cannot find the appropriate basic object-
require lexical retrieval such as word-picture matching (Huff
level terms (Bayles & Tomoeda, 1983; Martin & Fedio, 1983).
Relatedly, we observed an important difference in the type of
semantic substitution that was associated with verbs compared
with nouns: AD patients' semantic naming errors rarely
et al., 1986,1990; Martin & Fedio, 1983), category membership
judgments of words and pictures (Grossman, D'Esposito, et
al., 1996), and anomaly judgments of pictures and simple
subject-predicate sentences (Chertkow & Bub, 1990a; Grossman & Mickanin, 1994; Grossman, Mickanin, et al., 1996).
This evidence has been supplemented by careful analyses of
confrontation naming errors in AD that demonstrate frequent
semantic and superordinate substitutions (Bayles & Tomoeda,
1983; Martin & Fedio, 1983). In the present study, we observed
difficulty on confrontation naming as well as word-picture
matching, consistent with the hypothesis that a semantic memory
impairment contributes to naming difficulty in AD. We also found
that AD patients are more impaired with verbs than nouns on both
tasks. This confirms our previous observation of greater
naming difficulty for verbs than nouns on a set of homophonic
and homographic stimuli (Robinson et al., 1996).
We found little support in the present study for an alternative possibility, namely, that verb meaning may be selectively
supported in part by grammatical aspects of verbs, resulting in
relatively greater accuracy naming with verbs than nouns in
AD. Our assessment instead revealed that verb grammatical
information has little impact on verb naming accuracy. Shapiro
and colleagues (Shapiro, Gordon, Hack, & Killackcy, 1993;
Shapiro & Lcvine, 1990; Shapiro & Nagel, 1995) have demonstrated in an elegant series of studies that the number of
different sentence frames associated with a verb plays a crucial
role in verb processing. However, this effect appears to be
salient only for verb processing in a sentence context.
AD is a heterogeneous disorder that can interfere with
confrontation naming at several levels of processing in different patient subgroups. Previous studies have underlined broad
differences in cognitive and regional brain activity profiles
within AD (Grady, Haxby, Schlageter, & Berg, 1986; Haxby,
Duara, Grady, Cutler, & Rapoport, 1985; Haxby, Grady, Koss,
& Horwitz, 1988; Martin, Brouwers, & Lalonde, 1986; Schwartz,
1990). In the present study, individual patient analyses identified a subgroup of 12 AD patients likely to have a semantic
memory impairment. These patients were relatively impaired
across both confrontation naming and word-picture matching
tasks. Most of these AD patients were more compromised with
verbs than nouns on both tasks. This form class-sensitive
consisted of superordinate substitutions for verbs, although
superordinate semantic substitutions were frequently observed
for nouns. This pattern was also evident in the subgroup of AD
patients likely to have a semantic memory impairment. Redundant and overlapping information is more likely to resist
degradation as semantic memory processing becomes impaired in AD, and this may assist AD patients in their naming
with nouns compared to their naming with verbs. Verb matrix
relations, by comparison, are sparser and much less redundant,
and this may result in more difficulty naming with verbs than
nouns.
A second possible explanation for the form class-sensitive
naming difference in AD is that verbs contain more information than nouns—including at least semantic meaning, argument structure, and grammatical information. Verbs thus may
require more cognitive processing resources than nouns. AD
patients are known to have limitations in such working memory
resources (Baddeley, Logic, Bressi, Delia Sala, & Spinnler,
1986; Morris, 1994), and verb processing thus may be relatively
compromised because of the greater resource demands associated with verb processing than noun processing. Indeed, the
subgroup of AD patients with greater difficulty for verbs than
nouns on both confrontation naming and word-picture matching tasks had a lower MMSE score and thus may have had
relatively limited cognitive processing resources than the AD
patients who did not manifest a form class-specific effect. This
discrepancy in MMSE could not fully account for the form
class-sensitive subgroup differences, but additional work is
needed to assess the contribution of resource limitations in
AD patients' verb processing.
A third possible explanation for greater verb-naming difficulty in AD is related to the claim that lexical retrieval may
vary depending on the form class of the target word. Several
sources of evidence suggest that AD patients have a wordretrieval deficit. For example, much of the naming deficit in
AD is said to disappear when the patients are given choices of
names in a word-picture matching context (Huff et al., 1990).
Using an entirely different technique, a recent study demon-
502
WHITE-DEVINE ET AL.
strated that the pattern of paraphasias in AD patients'
word-use errors is most consistent with a lexical retrieval
deficit (Biassou et al., 1995). The findings of the present study
are consistent in part with the view that lexical retrieval is
compromised in AD. Thus, we found that AD patients
perform worse on a confrontation naming task than on a
word-picture matching task. We sought evidence for a form
class-specific lexical retrieval deficit in AD in the context that
several patients with focal cerebral insult have been described
with selectively greater difficulty retrieving verbs or nouns
(Caramazza & Hillis, 1991; Damasio & Tranel, 1993; Hillis &
Caramazza, 1991; McCarthy & Warrington, 1985; Miceli et al.,
1984, 1988; Zingcser & Bcrndt, 1990). A performance profile
in keeping with a deficit to a form class-specific output lexicon
would include consistently greater difficulty naming with verbs
or nouns, particularly among AD patients who do not have a
semantic memory impairment. However, this was not found. A
previous evaluation of AD patients' spontaneous speech on a
picture description task has revealed a fairly normal distribution of nouns and verbs (Blanken et al., 1987). A lexical
retrieval impairment thus appears to contribute to confrontation naming difficulty in AD, but this deficit does not appear to
be associated with a compromised form class-specific output
lexicon.
Several additional shortcomings must be kept in mind when
considering our findings. The critical contrasts in our study
were within-subject comparisons in the AD group, although a
ceiling effect in neurologically intact control participants
limited our ability to interpret groupwidc contrasts between
AD patients and control participants. The confrontation
naming results reported here replicate AD patients' relative
difficulty naming with verbs found in a previous study (Robinson et al., 1996), but the verb-picture matching deficit requires
replication with another technique that does not involve lexical
retrieval. Confrontation naming was assessed orally, but the
word-picture matching task used written word stimuli, so
additional studies are needed to rule out the possibility that
AD patients have a lexical retrieval deficit for verbs restricted
to the oral modality. With these caveats in mind, we conclude
that naming difficulty in AD is multifactorial. A semantic
memory impairment contributes to AD patients' naming
difficulty, and we hypothesize that consistently greater difficulty naming with verbs than nouns is due in part to differences
in processing the mental representation of these words in
semantic memory. A lexical retrieval impairment also appears
to contribute to AD patients' naming difficulty, although this
does not apparently compromise a form class-specific output
lexicon.
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Received July 13,1995
Revision received March II, 1996
Accepted March 11,1996