Brain (1983), 106, 613-622

DRAWING OBJECTS FROM MEMORY

IN APHASIA
by GUIDO GAINOTTI, MARIA CATERINA SILVERI,
GIAMPIERO VILLA and CARLO CALTAGIRONE
{From the Institute of Neurology, Catholic University, Largo A. GemelH8, 00168 Roma, Italy)

SUMMARY
The ability of aphasic patients to draw from memory objects with a characteristic shape has been
investigated. Their capacity to reproduce the form of real objects was studied by showing them for a
short time line drawings of simple objects. When the patient had analysed and recognized the figure,
the model was hidden from view and the subject was asked to draw the same object from memory. This
Drawing from Memory task was administered to 54 aphasics, 67 patients with right hemisphere
lesions, 44 nonaphasic left brain-damaged patients and 23 normal controls. The influence of
visuoconstructive disabilities was controlled by administering to the same patients a standard test for
constructional apraxia (copying 10 geometricalfigures).The severity and clinical form of the aphasia
and the presence of semantic-lexical impairment at the receptive level were also examined in the aphasic
patients. The following results were obtained. (1) Aphasic patients scored significantly less well than
the control groups on the Drawing from Memory task and the intergroup differences became greater
when the scores from the test for constructional apraxia were included by an analysis of covariance. (2)
No significant correlation was detected between the severity and clinical form of the aphasia and the
scores obtained on the Drawing from Memory task. (3) There was a significant correlation between
impaired drawing from memory and disruption at the semantic-lexical level of language integration.

INTRODUCTION

In recent years several investigations have shown that aphasic patients may exhibit a
variety of nonverbal disturbances in addition to their well-established linguistic
disorders. It has been shown, for example, that these patients are often unable to
recognize the source of a familiar nonverbal sound (Spinnler and Vignolo, 1966;
Faglioni et al., 1969), fail to understand the meaning of simple pantomimes (Duffy
et al., 1975; Gainotti and Lemmo, 1976), are unable to associate the form of an
object with its colour (De Renzi et al., 1972) and are severely impaired in tasks of
abstract thinking (De Renzi et al., 1966) and of conceptual judgement (Gainotti et
al., 1979). The meaning of these disturbances, however, remains controversial.
Some authors (for example, Gainotti et al., 1979) have claimed that a functional
relationship exists between linguistic and extralinguistic disturbances. Other
authors {see De Renzi et al., 1966) have suggested that aphasia and nonverbal
disturbances could be due to a lesion of anatomically contiguous but functionally
independent cortical areas.
614 GUIDO GAINOTTI AND OTHERS

The aim of the present study was to assess whether aphasic patients are also
impaired when they are requested to draw from memory the form of objects with
a characteristic shape. Scattered observations on this subject already exist in the
neuropsychological literature, but no systematic investigation has been undertaken
to study this problem in a controlled experimental situation. Head (1926) and Bay
(1962, 1964) noticed, for example, that aphasic patients are often unable to draw
from memory objects having a characteristic shape (or to model them with plastic
material). Bay, in particular, claimed that aphasic patients generally do not
reproduce in their drawings (or models) those 'essential details' which are necessary
for a clear and unequivocal identification of an object and attributed this to a basic
conceptual disorder.
Further data pointing to a specific difficulty for aphasic patients to draw objects
from memory was obtained by Duensing (1953), Piercy et al. (1960) and Gainotti
et al. (1972), who showed that the presentation of a model to copy considerably
improves the drawing ability of aphasic left brain-damaged patients, but does not
facilitate the performance of right brain-damaged patients with constructional
apraxia.
Other authors, however, objected to the concept of a specific impairment in
aphasic patients for drawing objects from memory. They noted that painters
affected by aphasia do not necessarily lose their artistic capabilities (Alajouanine,
1948; Gourevitch, 1967; Kornyey, 1977) and that patients with severe expressive
aphasia can sometimes use their residual drawing abilities as a form of communica-
tion (Hatfield and Zangwill, 1974; Pillon et al., 1980).
A critical discussion of the published data is rendered difficult by methodological
inconsistencies in the previous studies. The capacity of aphasic patients to draw
objects from memory has generally been studied in individuals or in very small
groups of patients and investigated by uncontrolled clinical procedures. The
performance of aphasic patients has not been compared with control groups of
nonaphasic brain-damaged patients. No systematic attempt has been made to
control the influence of associated variables, such as a defect of verbal compre-
hension (if the objects to be drawn had simply been named by the examiner) or the
influence of constructional apraxia, which may have a deleterious effect on the
performance obtained by aphasic patients in a drawing task.
The present study was therefore designed to clarify, in a more precisely controlled
manner, the following issues. (1) Are aphasic patients significantly more impaired
than right brain-damaged patients or left brain-damaged patients without any
aphasia on a test of drawing objects from memory? (2) Is impaired drawing from
memory in aphasic patients only a consequence of a more general visuoconstruc-
tional disorder or is this defect still evident when variance associated with
constructional apraxia is removed? (3) Can a significant relationship be found
between impaired drawing from memory and the clinical form of the aphasia, the
severity of language disorder, and impairment at the semantic-lexical level of
language integration?
 DRAWING OBJECTS FROM MEMORY IN APHASIA 615

MATERIAL AND METHODS

Testing Procedures
Drawing from Memory test. The capacity of aphasic patients to reproduce from memory the form of
real objects was studied with a nonverbal procedure, namely, showing the patients for a short time line
drawings of simple objects chosen because they have a characteristic shape. These objects were a nail,
a pear, a key, an arrow, a glass, a comb, a cluster of grapes, a table, a hand and an umbrella. When the
patient had analysed and recognized the object (usually by naming it), the model was hidden from view
and the subject was asked to draw the same object from memory. The following score was given for
each drawing: 2 points if the object could be easily recognized with the drawing containing most of its
characteristic details; 1 point if the object contained only a few of its characteristic details but could still
be recognized; zero if the object was not recognizable. Two independent judges evaluated all the
drawings and the sum of their scores formed the 'drawing from memory score' obtained by each
individual patient. Since the test consisted of 10 items and each drawing was evaluated by two judges,
the maximum score obtainable was 40.
Copying drawings. To test for constructional apraxia, all patients received a test of copying
geometrical drawings proposed by Arrigoni and De Renzi (1964). This test consists of 6 models, the last
2 of which are composed of 3figures,so that a total of 10 geometrical drawings are presented to the
subject to copy. For each patient the copy scored 2points for essentially correct reproduction, 1 point if
the copy was partly defective (omission of some lines, rotation, distortion or size errors) but not to such
an extent as to prevent the identification of thefigure,and zero for unrecognizable reproduction. As
for the Drawing from Memory test, two independent judges evaluated all the copies and the sum of
their scores formed the 'copying drawings score' for each patient. The maximum score obtainable was
again 40.
Assessment of type and severity of aphasia. To study the relationship between impaired drawing from
memory and the clinical form and severity of aphasia, left brain-damaged patients received a standard
test for the examination of aphasia currently used in our clinic. Patients defined as aphasic were divided
into 4 major aphasic syndromes (Broca's, Wernicke's, anomia and conduction aphasia) according to
•the following behavioural criteria.
Broca's aphasia: reduced speechflow,with articulatory disorders and agrammatism or disprosody;
comprehension good or moderately impaired.
Wernicke's aphasia: normal of logorrhoeic speech flow, with phonemic and verbal-semantic
paraphasias, neologisms and moderate to severe disorders of language comprehension.
Anomia: appreciable difficulties in word finding, without articulatory disorders and with few
phonemic or verbal-semantic paraphasias; comprehension good or mildly impaired.
Conduction aphasia:fluentspeech without articulatory disorders but with impaired repetition and
frequent phonemic paraphasias; comprehension good to mildly impaired.
The quantity of communication possible in oral expression and in auditory comprehension was taken
as an index of the severity of aphasia. Language disorder was rated as mild when patients showed only
a slight anomia, rare phonemic or verbal-semantic paraphasias or a mild syndrome of phonetic
disintegration, without obvious comprehension disorders. Aphasia was rated as moderate when
anomia, phonemic or verbal paraphasias and articulatory disorders were more evident and when clear
disturbances were also observed at the receptive level. The aphasic syndrome was rated as severe when
verbal comprehension was poor and expressive language was limited to incomprehensible jargon or to
few recurring utterances.
Impairment at the semantic-lexical level of integration of language. The presence of semantic-lexical
impairment was studied by administering to all the aphasic patients the Verbal Sound and Meaning
Discrimination test (Gainotti et ai, 1975). It is sometimes difficult to assess the presence of a semantic-
lexical disorder at the expressive level, since other expressive disturbances can mask the semantic
616 GUIDO GAINOTTI AND OTHERS

disorder and render its detection difficult. On the other hand, semantic impairment can be detected
more readily at the receptive level by asking patients to discriminate the meaning of a given word
by choosing from an array of semantically similar alternatives the object corresponding to the
stimulus word. The Verbal Sound and Meaning Discrimination test has already shown itself to be
particularly useful from this aspect (Gainotti et al., 1975; Gainotti and Lemmo, 1976; Gainotti et al.,
1979) and was therefore also employed in this study. Patients with more than 3 semantic discrimination
errors on the Verbal Sound and Meaning Discrimination test were considered to be impaired at
the semantic level (3 was the worst score attained by more than 95 per cent of normal controls), whereas
patients with less than 3 semantic discrimination errors were considered as free from semantic-lexical
impairment.

TABLE 1. AGE, SEX, EDUCATION AND AETIOLOGY OF THE SUBJECT GROUPS

Aetiology

Mean age Years of Neoplastic

Subject group (yrs) M F schooling Vascular + others
Normal controls 52.45 13 10 8.95
(n = 23) (SD = 12.8) (SD = 4.8)
R. brain damage 59.92 36 31 8.35 41 26
(n = 67) (SD=13.1) (SD = 4.87)
Nonaphasic L. brain 50.42 23 21 8.51 30 14
damage (n = 44) (SD = 14.3) (SD = 4.3)
Aphasics 57.23 36 21 9.37 38 19
(n = 57) (SD = 13.8) (SD = 4.9)

Broca (n = 16) 54.64 9 7 7.55 11 5

Conduction (n = 7) 64.16 5 2 11.43 6 1
Wernicke (n = 24) 59.50 16 8 9.11 15 9
Anomics (n = 10) 51.44 6 4 8.25 6 4

In addition to the semantic distractors, this test also includes phonological and irrelevant distractors
so that, besides the semantic discrimination errors, it is also possible to assess phoneme discrimination
errors and unrelated errors (Gainotti et al., 1975). No account was taken of these errors in the present
study since our aim specifically consisted of assessing semantic-lexical impairment and only semantic
discrimination errors were considered as relevant.

Subjects
The Drawing from Memory test and the Copying Drawings test were given to 57 aphasics, 67
patients with right hemisphere lesions and 44 nonaphasic left brain-damaged patients. Furthermore,
23 normal controls, showing no signs of CNS impairment, also received both tests. Brain-damaged
patients were unselected. However, left-handed subjects, patients with clinical signs (or case histories)
pointing to diffuse or obviously bilateral brain damage and subjects unable to carry out the drawing
tasks (owing to paralysis of the right hand) were excluded. Table 1 gives the relevant clinical data (age,
sex, education and aetiology of illness). No significant differences were found either between aphasic
patients and any of the control groups or between the different aphasic syndromes, with respect to age,
sex, education and aetiology of the brain pathology.
 D R A W I N G OBJECTS FROM MEMORY IN APHASIA 617

RESULTS

Scores Obtained by Aphasic and Nonaphasic Patients on the Tasks of Drawing from
Memory and Copying Drawings
Table 2 gives the mean scores obtained by aphasics, normal controls, and
nonaphasic right and left brain-damaged patients on the Drawing from Memory
test and on the Copying Drawings test. A two-way analysis of variance for repeated
measures, with an unequal number of observations within the various cells, gave a
significant F value for both the main effects (type of task and diagnostic group) and
the interaction. Separate post-hoc comparisons between the aphasics and the other
diagnostic groups showed that aphasics are significantly more impaired than any
other group on the Drawing Objects from Memory test, but not on the test for
constructional apraxia. In particular, no difference was found between aphasics and
right brain-damaged patients (which can be considered as the most appropriate
control group) on the Copying Drawings test. This finding strongly suggests that
impaired drawing from memory in aphasic patients is a symptom independent from
constructional apraxia and cannot be considered as a particular aspect of a more
general visuoconstructive disorder.

TABLE 2. RESULTS OBTAINED BY APHASICS, NORMAL CONTROLS AND NONAPHASIC

BRAIN-DAMAGED PATIENTS ON THE TASKS OF DRAWING OBJECTS FROM MEMORY
AND OF COPYING GEOMETRICAL DRAWINGS

Aphasic R. brain- Nonaphasic Normal

patients damaged L. brain-damaged controls
{n = 57) {n = 67) (n = 44) in = 23)
Mean scores
Drawing from Memory 21.59 28.08 31.16 33.78
Copying Drawings 33.83 33.53 37.70 37.04

Overall analysis of variance

Variable df F P
Type of task 1 111.56 < 0.001
Diagnostic group 3 30.90 < 0.001
Interaction 3 5.78 <0.01

Separate comparisons between aphasics and other diagnostic groups

Drawing Objects from Memory
Aphasics vs R. brain-damaged t = 4.012 P < 0.001
Aphasics vs nonaphasic L. brain-damaged t = 6.326 P < 0.001
Aphasics vs normal controls t = 6.315 P < 0.001
Copying Geometrical Drawings
Aphasics vs R. brain-damaged t = 0.258 Pn.s.
Aphasics vs nonaphasic L. brain-damaged t = 4.057 P < 0.001
Aphasics vs normal controls t = 2.016 P <0.05
618 GUIDO GAINOTTI AND OTHERS

In order to study the problem more closely, scores obtained on the Drawing from
Memory test were submitted to an analysis of covariance using age, educational
level and copying drawings scores as covariates. Adjusted mean scores for aphasics,
normal controls and nonaphasic right and left brain-damaged patients on the
Drawing from Memory test are given in Table 3, together with the results of the
overall analysis of variance and with the post-hoc comparisons between aphasics
and other diagnostic groups. Results of this analysis confirm that defects in drawing
from memory in aphasic patients are independent from visuoconstructive disorders,
since they are still evident when variance associated with constructional apraxia has
been removed from analysis.

TABLE 3. ADJUSTED MEAN SCORES FOR APHASICS, NORMAL CONTROLS AND

NONAPHASIC BRAIN-DAMAGED PATIENTS ON THE DRAWING FROM MEMORY TASKS

Adjusted mean scores

Nonaphasic
Aphasics R. brain-damaged L. brain-damaged Controls
20.81 27.34 27.00 30.49

Statistical analysis
Analysis of covariance F ( 1 1 5 1 ) = 16.89 P < 0.001
Post-hoc comparisons between aphasics and other groups by the Tukey test' (t crit. 0.001 = 4.08)
Differences between mean scores Aphasics—R. brain-damaged = 6.53
Aphasics—nonaphasic L. brain-damaged =6.19
Aphasics—controls = 9.68

Relationship between Impaired Drawing from Memory and Clinical Aspects of

Aphasia
When a more detailed study of the relationship between impaired drawing from
memory and clinical aspects of aphasia was undertaken, it was found that neither
the clinical type nor the severity of aphasia are significantly related to the inability to
reproduce from memory the form of real objects. In fact, no significant difference
was found between the drawing from memory scores obtained by Broca, Wernicke,
anomic and conduction aphasic patients nor among the scores obtained by patients
with a mild, moderate or severe form of aphasia. Table 4 gives the mean values
for the scores obtained on the Drawing from Memory test and on the Copying
Drawings test by patients classed in the various aphasic syndromes or rated as
showing different levels of severity of aphasia.
Since no significant difference was found between the various aphasic syndromes
or between the various levels of severity of aphasia, neither of these variables seems
critical to the deficit in drawing from memory of aphasic patients. On the contrary,
a significant relationship was found between impaired drawing from memory and
breakdown at the semantic-lexical level of integration of language, as shown in
 DRAWING OBJECTS FROM MEMORY IN APHASIA 619

TABLE 4. RELATIONSHIPS BETWEEN CLINICAL FORM AND SEVERITY OF APHASIA

AND RESULTS OBTAINED ON THE TASKS OF DRAWING OBJECTS FROM MEMORY
AND OF COPYING DRAWINGS

Clinical form of aphasia: mean scores

Broca Anomia Wernicke Conduction
in = 16) in = 10) in = 24) in = 7)
Copying Drawings 34.52 34.23 34.71 33.03
Drawing from Memory 18.74 23.32 21.78 23.10

Mean scores obtained by patients showing

various levels of severity of aphasia
Mild Moderate Severe
in = 23) in = 23) in = 11)
Copying Drawings 34,78 33.60 33.55
Drawing from Memory 23.78 18.48 21.60

TABLE 5. RELATIONSHIPS BETWEEN SEMANTIC-LEXICAL IMPAIRMENT AND

SCORES OBTAINED ON THE TASKS OF COPYING DRAWINGS AND OF
DRAWING FROM MEMORY

Mean scores obtained by aphasic patients with and without semantic-lexical impairment
Presence of semantic- Absence of semantic-
lexical impairment lexical impairment
in = 30) in = 27)
Copying Drawings 33.54 35.62
Drawing from Memory 17.52 26.33

Overall analysis of variance

Variable df F P
Type of task 1 101.38 < 0.001
Presence/absence semantic-lexical impairment 1 18.72 < 0.001
Interaction 1 3.57 <0.05

Table 5. Patients who had made a 'normal' number of semantic errors on the Verbal
Sound and Meaning Discrimination test scored significantly better on the Drawing
from Memory test than patients presenting a semantic-lexical impairment (t = 2.38;
P < 0.05). No difference was found between the two groups of aphasics when scores
obtained on the Copying Drawings test were taken into account.

DISCUSSION

The main results of the present investigation can be summarized as follows.

(1) Aphasic patients are significantly more impaired than right and nonaphasic
left brain-damaged patients on a test of drawing objects from memory. (2) This
impairment cannot be considered as an aspect of a more general visuoconstructive
620 GUIDO GAINOTTI AND OTHERS

disturbance, since it remains significant even when variance associated with

constructional apraxia has been removed: (3) No correlation can be found between
impaired drawing from memory and the severity or clinical form of aphasia. On the
contrary, a significant relationship can be observed between impaired drawing from
memory and breakdown at the semantic-lexical level of language integration.
Since our study did not include a condition in which subjects were asked to
draw 'nonsense' drawings from memory, we cannot exclude that poor results
obtained by aphasic patients were due to a short-term visual memory defect and not
to a conceptual inability to reproduce from memory the form of objects having
a characteristic shape. Several reasons, however, make this interpretation rather
implausible. (1) This interpretation is not economical, since it assumes that aphasic
patients may also have an independent short-term visual memory defect. (2) The
examiner did not ask the patient to reproduce from memory a more or less
meaningful shape, but tried to raise in the patient the concept of the object (for
example, by naming it) and then asked the patient to draw the named object. (3) It
has been demonstrated by Faglioni and Spinnler (1969) that right brain-damaged
patients, and not aphasics, are particularly impaired in tasks of immediate and
delayed memory of meaningless visual patterns.
All these reasons support Bay's statement, that aphasic patients are unable,
because of a basic conceptual disorder, to reproduce from memory those essential
details which are necessary for a clear identification of an object (Bay, 1962, 1964,
1974) rather than a short-term visual memory defect hypothesis. Some of the present
results (for example, the relationship between drawing from memory impairment
and breakdown of the semantic-lexical system) seem to show that the hypothesis
advanced by Bay could perhaps be formulated in more precise terms by admitting
the existence, within the aphasic patients, of a selective relationship between
conceptual and semantic-lexical disintegration. This last formulation also has the
advantage of being compatible with the existence of aphasic individuals who have
demonstrated excellent capabilities in drawing objects from memory, since it is
possible that language disturbances in these subjects were due more to phonological
and/or phonetic disorders than to a central semantic-lexical impairment.
Results pointing in this direction have recently been obtained by Gainotti and
Lemmo (1976), Whitehouse et al. (1978), Gainotti et al. (1979) and Caramazza et al.
(1982). Gainotti and Lemmo (1976) have shown that aphasic patients are
specifically impaired on a nonverbal test of symbolic gesture interpretation and that,
within the aphasic group, the inability to understand the meaning of symbolic
gestures is highly related to semantic-lexical disturbances. Similar findings have
been obtained by Gainotti et al. (1979) with a nonverbal test of 'conceptual
thinking'. Aphasic patients were selectively unable to appreciate the relationship
existing between the picture of a simple object and pictures of other objects having
different levels of conceptual similarity with the stimulus. Furthermore, an
important correlation was found, within the aphasic patients, between semantic-
lexical deficits and conceptual impairment.
 DRAWING OBJECTS FROM MEMORY IN APHASIA 621

Also very relevant to the problem of the relationship between conceptual and
semantic-lexical disintegration are the results obtained by Whitehouse et al.
(1978) and by Caramazza et al. (1982), using a model of conceptual representation
recently developed by Labov (1973) and by Miller and Johnson-Laird (1976). These
authors administered to a group of anomic and to a group of Broca's aphasic
patients a series of line drawings of food containers, varying in physical features
(such as the diameter-to-height ratio and the presence or absence of a handle) and
presented in a variety of contextual situations (a coffee pot, a cereal box and a
pitcher of iced water). Their aim was to explore the interaction of perceptual and
functional information in the act of selecting the most appropriate name for the
depicted object from a multiple choice list including 'cup', 'bowl' and 'glass'.
Normal controls and Broca's aphasic patients were able to integrate in a predictable
way perceptual and functional information in order to choose the proper name for
each stimulus, whereas anomic patients were not influenced in their choice of the
verbal label either by perceptual or functional information. In interpreting these
data, Caramazza et al. (1982) assumed that the perceptual parsing of an object (for
categorization and eventually for naming) may be guided by semantic considera-
tions (that is, by the set of features that are represented as part of the concept of the
object). The inability of anomic patients to classify the stimuli correctly might
be due, from this point of view, to a conceptual-semantic disorder affecting the
perceptual parsing process in its 'top-down', semantically orientated stage. A very
similar interpretation could be advanced, in our opinion, to explain most of the
nonverbal disturbances shown by aphasic patients with semantic-lexical impair-
ment. In particular, a defect of the conceptual organization underlying word
meaning could explain their inability to reproduce from memory the form of
objects, if we assume that perceptual properties are represented as part of the
concept of an object, either directly or in verbal terms.
It is possible, on the other hand, that some aspects of the semantic representation
may be more impaired than others in aphasic patients with semantic-lexical
disorders. Goodglass and Baker (1976) have shown, for example, that some features
of meaning are very impaired in aphasic patients with comprehension disorders,
whereas other features are relatively spared. Furthermore, it seems to us that the
drawing from memory defect studied in the present investigation was less clearly
linked to the semantic-lexical impairment than the conceptual thinking disorder
investigated in a previous study (Gainotti et al., 1979). A comparative assessment
of the levels of impairment presented by aphasic patients on various kinds of
nonverbal cognitive tasks could, therefore, be very informative in obtaining a better
knowledge of this complex and debated issue.

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