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aphasiology, 1999, vol. 13. no.

6, 495±509

Case Study
Mirror reading, writing and backward
speech in a woman with a head injury: a
case of conversion disorder

R E G I NA J OK E L and DA VI D CO NN
Baycrest Centre for Geriatric Care, University of Toronto, Toronto,
Ontario, Canada

(Received 18 May 1998 ; accepted 27 October 1998)

Abstract
This paper presents a case of a 46-year-old, right-handed female, L.R., admitted
to a behavioural neurology unit after sustaining a mild head injury. The patient
presented as a very complex case with di¬culties in neuropsychological,
emotional and medical domains. The unusual features of her backward speech,
and mirror reading and writing, evident upon admission, are described here.
Results of assessment are considered in relation to conversion disorder and
existing theories on mirror phenomena.

Introduction
Mirror writing is a script which runs in the opposite direction to the normal with
individual letters also being reversed (Critchley 1928). It is a phenomenon that has
been approached with a well-deserved fascination but, due to its complexity, the
mechanism(s) still remain(s) unclear. R. Lentilius in 1698 (in Critchley 1928) is
credited with the ®rst known publication on mirror writing in a left-handed girl
suåering from epilepsy. Nearly 200 years later, H. E. Buchwald (in Critchley 1928)
described three cases of right-handed individuals with paraplegia and mirror
writing due to injury. During the twentieth century an increasing number of cases
have been reported in the literature.
Most cases of mirror writing reported in the literature have been found in either
(L)-handed individuals (Critchley 1928 ; Strei¯er and Hofman 1976, Heilman et al.
1980, Wade and Hart 1991), or hemiplegics who, out of necessity, had to use their
non-dominant hand (Chia and Kinsbourne 1987, Hanakita and Nishi 1991,
Buxbaum et al. 1993). In several cases the mirror activity was not con®ned to the
language domain, but extended to other activities, e.g. object and spatial reversals
in carrying out every day tasks (Schott 1980, Feinberg and Jones 1984, Wade and
Hart 1991).
The aetiology and types of mirror writing have been classi®ed in many ways.
One of the currently used systems comes from Lebrun et al. (1989), who expand the
Address correspondence to : Regina Jokel, Department of Communication Disorders, Baycrest
Centre for Geriatric Care, 3560 Bathurst Street, Toronto, Ontario, M6A 2E1, Canada. e-mail :
rjokel! baycrest.org
Aphasiology ISSN 0268 ±7038 print} ISSN 1464 ±5041 online ’ 1999 Taylor & Francis Ltd
http:} } www.tandf.co.uk} JNLS} aph.htm http:} } www.taylorandfrancis.com} JNLS} aph.htm
496 R. Jokel and D. Conn

classi®cation provided by Critchley (1926) and describe the occurrence of mirror


writing as spontaneous, deliberate or involuntary.
(a) Spontaneous mirror writing can be seen in young children learning to write,
normal (L)-handers during ` switching ’ of hands and developmental dyslexics.
(b) Deliberate procedures, such as writing with both hands simultaneously, writing
on the underside of the table or on the forehead will yield mirror writing.
(c) Involuntary (acquired) writing may occur in stages of fatigue, confusion, slight
anaesthesia, hypnosis, daydreaming or hysteria and in hemiplegia (with the
non-preferred hand).
Tashiro et al. (1987) added two more categories to the above classi®cation system,
namely normal people, such as Leonardo daVinci (who apparently was dysgraphic
and perhaps dyslexic, Sartori 1987), and individuals with essential tremor,
Parkinson’s disease and spinocerebellar disorders.
Double mirror writing occurs when letter orientation is from R to L and upside-
down.
The occurrence of mirror writing, in such a diversity of conditions, prompted
the search for a theoretical explanation. Several have been delivered in the literature
over the past few decades.
(1) A motor hypothesis, introduced by Critchley (1926) stated that movements in the
non-preferred hand (or body part) will have the opposite spatial orientation to
those of the preferred hand (or body part).
(2) A visual hypothesis, entertained by Orton (1928), emphasized a visual, rather
than a movement, component. According to this hypothesis visual images in
each hemisphere are mirror images of each other and images in the non-
dominant hemisphere become suppressed.
(3) The spatial orientation hypothesis introduced by Heilman et al. (1979, 1980) and
Tankle and Heilman (1983) provided evidence for concurrent availability of
both the normally dominant and mirror engrams and associated the selection
of the mirror engrams with the failure of the R ±L spatial system.
(4) The directionality hypothesis by Chia and Kinsbourne (1987) took the issues
further and introduced the notion that mirror writing may occur due to a
speci®c motor programming ¯aw in the R±L action.
(5) The hemispatial crossactivation hypothesis was a successful attempt at explaining at
least one mechanism for mirror errors in writing. Buxbaum and colleagues
(1993) presented evidence from two (R)-handed hemiplegic individuals who
made more mirror errors in (R) hemispace than in (L) hemispace when using
their (L) hands to write.
Mirror reading is the ability to read mirror writing. Relatively little room has been
occupied in the literature by mirror reading compared to mirror writing, perhaps
because it is less common and does not always accompany mirror writing. On the
contrary, mirror writers often have di¬culty recognizing and} or reading their own
handwriting (Leonhard and Schott 1961, Corballis and Beale 1976, Downey 1914).
Although unilateral neglect after brain damage has been shown to produce mirror
reading (Denny-Brown 1963, Lebrun 1995), it seems that the handedness, rather
than brain injury, has a more signi®cant in¯uence on the ability to read mirror
writing (Annett 1991, Bradshaw and Bradshaw 1988).
Backward speech, or mirror-speech (Spiegelsprache, parole en miroir) has received
Mirror reading after head injury 497

very little attention in the literature ; in fact there is only a handful of published
cases. These cases provide a description of backward speech for experimental
purposes (Cowan et al. 1982, 1985, Cowan and Leavitt 1987), or consist of brie¯y
mentioned mirror speech without a more speci®c reference (Mitchell 1903, Pick
1904, Critchley 1928). Some are accounts of children capable of ¯uent backward
speech as a childhood game (Cowan and Leavitt 1982). The ®rst comprehensive
account of mirror speech was given by Critchley (1928), who viewed backward
speech as a transient anomaly in children learning to read. Reversed repetition of
digits was reported by Chia and Kinsbourne (1987) in a right-hand patient with a
basal ganglia haematoma. However, their patient did not represent the true
backward speech with full orthographic or phonological reversals as described in
other reports (Cowan and Leavitt 1987, Cocchi et al. 1986). Several variants of
backward speech have been described :
(a) Syllabic speech meant reversal of the order of syllables in a word with or
without reversals of the letters themselves (Critchley 1928).
(b) Syntactic backward speech is associated with reversal of word order in a
sentence or a phrase (Critchley 1928).
(c) The mixed type presents as a combination of literal±syntactic or syllabic±
syntactic forms of backward speech (Mitchell 1903).
Deliberate backward speech has been described in a woman with hysteria (Pick
1918 cited in Critchley 1928), who saw people upside-down and reversed word and
letter order while speaking (presumably producing orthographic reversals). Cowan
and Leavitt (1982, 1987) reported a case of two children, aged eight and nine,
speaking backwards as a language game. They both could speak backwards several
years later, with comparable error rate, but slightly reduced speed of response.
Cowan et al. (1982) documented another account of backward speech in an adult
who spoke backwards for experimental purposes.
Spontaneous backward speech was thought of as a curiosity of medicine (Critchley
1928). The only systematically described case of spontaneous backward speech
comes from Cocchi and his colleagues (1986), who reported on an Italian-speaking
man who spoke backwards after removal of an angiomatous meningioma in the
right temporal lobe. The surgery occurred when the patient was nine years of age
but, apparently, he retained the ability to speak backwards as an adult and, at the
time of publication, was just as ¯uent in both forward and backward speech. Their
patient did not exhibit mirror reading or writing.
In this paper we describe a patient who became a ¯uent mirror reader, writer and
backward talker after a head injury. The constellation of her symptoms was not
convincing enough to classify her de®cits as neurogenic. We could not ®nd a single
publication describing all three mirror phenomena as occurring simultaneously in
a single case of acquired de®cit. We also failed to ®nd the link between spatial and
temporal aspects of language that would explain the combination of problems seen
in our patient. At this point the diagnosis of conversion disorder was considered.

Conversion disorder
The term `conversion’ was ®rst used by Freud, who was referring to the
substitution of a somatic symptom for a repressed idea (Ford and Folks 1985).
Initial descriptions of conversion disorders are said to date back to 1900 bc, or
498 R. Jokel and D. Conn

earlier, and were felt to be related to ` a wandering uterus’ (Veith 1965). Hence, the
use of the term ` hysteria ’ from the Greek word for uterus (hystera). In the modern
era Briquet proposed that these symptoms occurred in predisposed individuals and
were related to stressful events that acted upon the aåective part of the brain.
Charcot theorized that a traumatic event led to an ` idea ’ that caused a `functional’
or `dynamic ’ lesion in the brain (Havens 1966). Freud and other psychoanalysts
believed that catharsis would bring the `idea ’ to consciousness, leading to
resolution of the somatic disorder. Conversion disorders are more common in
women and in lower socioeconomic groups, particularly in rural or less
psychologically sophisticated populations. The DSM-IV (American Psychiatric
Association 1994) criteria for conversion disorder include :

(a) one or more symptoms or de®cits aåecting voluntary motor or sensory


function that suggests a neurological or other general medical condition ;
(b) psychological factors are judged to be associated because the initiation or
exacerbation of symptoms is preceded by con¯icts or other stress ;
(c) symptoms are not intentionally produced, as in `factitious disorder ’ or
`malingering ’ ;
(d) it is unexplained by a general medical condition ;
(e) it is known to cause signi®cant distress.

Aetiological theories include psychodynamic, conversion as communication,


interpersonal manipulation, learned behaviour and neurophysiological hypotheses
(Ford and Folks 1985). The psychodynamic understanding of conversion is that the
symptom provides a solution to an unconscious con¯ict, most commonly between
basic drives (e.g. sexuality or anger) and inhibition of these by the superego.
Alternative psychodynamic explanations include identi®cation with a ` lost object ’
(most frequently a relative who has died) and an underlying need to suåer.
Conversion can also be considered to represent an alternative mode of com-
municating forbidden feelings or thoughts. It can be seen as an acceptable way of
adopting the sick role, resulting in avoidance of responsibility or control of others.
The symptom can also be conceptualized as having been learned earlier in life and
later utilized as a means of coping.
The possibility that conversion disorder has an underlying neurophysiological
component has received attention in recent years. Several authorities have proposed
corticofugal inhibition of aåerent stimuli as a possible explanation (Whitlock 1967,
Ludwig 1972). Galin et al. (1977), reported lateralizatio n of conversion symptoms
with increased frequency on the left side of the body. Flor-Henry et al. (1981)
reported bilateral neuropsychological impairment in patients with multiple
conversions with relatively greater dominant hemisphere impairment. Drake
(1993) described ®ve cases of ` conversion hysteria’ associated with dominant
hemisphere lesions. Three of the patients had suåered head injuries.
Coexisting psychiatric disorders are common, especially depression, personality
disorders and somatization disorder. In addition, patients frequently demonstrate
evidence of a previous or current neurological disorderÐ64% in one study
(Whitlock 1967). Slater and Glithero (1965) reported that, in more than 50 % of
their cases, organic disease was found on follow-up. Treatment approaches include
psychotherapy, behaviour modi®cation and techniques which utilize `suggestion’,
e.g. hypnosis and the sodium amytal interview.
Mirror reading after head injury 499

To our knowledge this is the only case of all three phenomena (mirror reading,
writing and backward speech), co-occurring in one person, and the ®rst report of
mirror phenomena in a patient with conversion disorder.

Case study
L.R. is a 46-year-old right-handed teacher who suåered a head injury in May 1994.
Apparently, a map fell and hit her in the (L) frontal area. While falling to the ¯oor,
L.R. sustained additional injuries, to the forehead (from hitting the blackboard)
and to the back of the head (from hitting the ¯oor). There is a report of loss of
consciousness for approximately 10 minutes and some minimal retrograde amnesia.
She was taken to the emergency department of a local hospital and released after a
brief period of observation. Shortly after returning home she began having
headaches and nausea, and experienced seizures. She was admitted to another
hospital. By that time she reported having approximately 60 to 70 seizures. They
were never witnessed by anyone else but her husband. He could not provide
enough detail for the medical staå to determine whether they were true seizures or
constituted a conversion response to emotionally charged situations at home. She
was put on prophylactic dose of Dilantin.
After her accident, L.R. tried to return to work in June 1994, but after a 3-week
trial period it became evident that she could not manage her job. Subsequently, she
was seen at the Worker’s Compensation Centre, but was denied compensation
because of a lack of neurologically based symptoms. Her condition slowly
deteriorated. She was admitted to yet another hospital, where ` no organic bases for
her symptomatology could be found ’ and in May 1995 she was transferred to the
Behavioural Neurology Unit. Upon her admission she reported di¬culties with
memory and concentration. She appeared depressed and reported photophobia and
hyperacusis. She could not construct grammatically correct sentences, read or write
in a regular fashion. She reported having daily headaches and problems with
perception and peripheral vision. Her calculation skills and face} voice recognition
were poor. She was observed to have walking di¬culties, with inversion of the left
foot to the point where she required a walker. Examination of cranial nerves
revealed mild facial asymmetry, without a droop or weakness, and inconsistent
response to visual stimuli in the (R) hemi®eld. Bilateral plantar extensor responses
were elicited, though they were thought to be a conversion response by the
examining neurologist because they could be easily elicited by stimulating uni- and
contralateral palms, while the neurologist explained the ` expected ’ outcome to a
group of attending professionals. After ®nding out that she had been ` tricked ’,
L.R. stated : `That was not fair, you know that I am suggestible ’.
Her past medical history was marked for hiatus hernia, appendectomy, asthma
and asymptomatic spina bi®da occulta. She had also serum sickness following
rabies shots in the mid-1970s. At the time of admission her medications included
Zantac, Ventolin and Dilantin. L.R. had several neuroimaging studies (MRI, CAT
scan, SPECT scan), done after her accident, all of which were normal. Numerous
EEG tests done over the span of several months were also normal.
She also experienced a dramatic change in her personality and was quoted as
saying: ` I am not me. ’ Her family con®rmed this change, and so her childlike
behaviour, irritability, anxiety, fearfulness and aggression were added to the long
list of current problems. In addition, she showed impairments in her ability to
500 R. Jokel and D. Conn

perform basic daily tasks such as food preparation, taking a bath, making decisions
about ®nances and solving simple problems. During the course of L.R.’s
hospitalization new problems included insomnia, anorexia, and many others. She
was eventually discharged to a psychiatric facility after an attempt to stab a nurse
with a kitchen knife, which she secretly took to her room after supper.
In her professional life, L.R. was regarded as an `overachiever ’ and a ` super-
teacher ’ about to complete coursework for a PhD degree in special education.

Procedure
Sodium amytal interview
Because of the complexity of her symptoms, and di¬culties with diåerential
diagnosis, L.R. was asked to participate in a sodium amytal interview. This
technique was ®rst introduced by Bleckwenn in 1930 as a form of treatment for
psychotic patients. This technique should not be confused with the Wada procedure
in which sodium amytal is given via the carotid artery as an indicator of laterality
of brain functions, such as language. In the sodium amytal interview the medication
is given slowly via intravenous injection, during which time the subject is actively
engaged in conversation. Despite being used for many diåerent psychiatric
conditions, especially during the 1930s and 1940s, current indications are more
clearly de®ned (Perry and Jacobs 1982) ; they include diagnostic applications in the
care of patients who are mute, stuporous or catatonic. The sodium amytal
interview is also used as a therapeutic application for the following conditions :
(a) recovery of function in conversion disorder,
(b) recovery of memory in psychogenic amnesia and fugue,
(c) abreaction of post-traumatic stress disorder.
In this case sodium amytal 500 mg was given slowly via an intravenous route over
a period of approximately 1 hour, as described by Perry and Jacobs (1982).

Language testing
L.R. was assessed over a 2-week period in May 1995. All four language modalities
were assessed with the Boston Diagnostic Aphasia Exam (BDAE), Boston Naming
Test (BNT) and several non-standardized measures. Neuropsychological as-
sessment was attempted but not completed due to L.R.’s poor compliance, hostility
and low reliability of responses. Special tasks described in the literature as inducing
mirror writing were employed to see if they could help L.R. with production of
correctly oriented handwriting (Lebrun et al. 1989). Given the fact that all tasks
used in regular testing produced mirror writing, the hope was that, perhaps, special
tasks would produce regular writing, since L.R. considered mirror writing
` normal’ for her. She was asked to complete all writing tasks with both hands
simultaneously and one hand at a time, (a) centrifugally, (b) centripetally, (c)
starting from the left side of the page, (d) right side of the page, (e) on her forehead
and (f) under the table.
Mirror reading after head injury 501

Results
Sodium amytal interview
L.R. was very anxious and agitated prior to the interview but agreed to cooperate
with the procedure. Under the in¯uence of the `truth serum ’ L.R. began to count
backwards. It was then, 1 year after the initial trauma, that her mirror speech was
heard for the ®rst time. She said } eno} , } oowt} , } eerht} , etc. reversing the words
according to their orthography. After the interview her backward speech was
heard more often and with increasing ¯uency.
During the interview L.R. was able to describe her early life and family
relationships. There was no evidence of major trauma or physical} sexual abuse in
childhood, although her father was an alcoholic. There was evidence of major
con¯ict in her marriage. She described her husband as ` infantile ’ and stated that she
and her husband did not have an active sexual relationship.

Language
Verbal expression
Spontaneous forward speech was ¯uent but marked by occasional paucity and
syntactic errors. L.R. frequently omitted functor words (and, of, for, to) and used
incorrect grammatical morphemes, i.e. ` I am go ’, `she do no ’Ðreferring to the past
tense (she did not), etc. Backward speech pattern was characterized by exaggerated
prosody and complete orthographic and} or phonologic reversals. L.R.’s verbal
` Cookie Theft ’ picture description was as follows : Ereht, ereht si a lrig dna a yob
(There, there is a girl and a boy). Yob is (not reversed) gnidnats no eht loots dna lrig
(¼) eikooc (Boy is standing on the stool and girl (¼) cookie). Dna yob is gnitteg eikook
morf eht eikooc raj (And boy is getting cookie from the cookie jar). Tap ! Dna eht loots
si gnillaf (Pat ! And the stool is falling). I kniht, I kniht taht (¼) gniog ot llaf (¼) roolf
(¼) teg a daeh yrujni (I think, I think that (¼) going to fall (¼) ¯oor (¼) get a head
injury). Description of the same picture carried out on demand in a regular,
forward fashion was characterized mostly by syntactic errors, i.e. incorrect word
order and was as follows : The, boy, aah ¼ this is a, is a boy and a girl is, for, for cookies
to get. The boy standing the stool is on. Girl the, girl the cookie wants a. And boy the falling
is the stool oå. And head injury I think he will get. I, the lady think I, is there standing at
the sink, why to wash dishes the. A plate in her hands has a she, is the water coming is o-ver-
¯o-wing, yes, over-¯owing, over¯owing the sink and she standing in the water is. It is
noteworthy that while the content of both versions was very comparable, L.R. was
able to articulate 110 syllables within 1 minute during the forward description (89
words), but needed twice as much time for her backward description (42 syllables} 1
minute). Nonetheless, perceptually, the backward speech sounded relatively ¯uent.
Repetition of sentences was impaired (1} 5, BDAE) and marked by word
omissions, incorrect word order and errors made during the ` translation ’ process
(` Earth down ’ for Down to earth). Naming (in a mirror fashion at L.R.’s request) was
impaired (40} 60, BNT). Errors represented predominantly circumlocutions (` sticks
on the house ’ for trellis), phonemic paraphasias (`protector’ for protractor), semantic
paraphasias (` sphinx ’ for pyramid) and instances of anomia (` like the other one ’ for
accordion, making a reference to harmonica). Of note is that while some words were
entirely correct in their reversed form (} rewolf} for ¯ower, } ebolg} for globe),
502 R. Jokel and D. Conn

(a)

(b )

Figure 1. (a) part of L.R.’s original description of her di¬culties ; (b) L.R.’s description copied from
a transparency in a regular fashion to facilitate readability.

others were not (} lertzep} for pretzel, } srokis} for scissors). The actual responses
are presented in the Appendix.

Auditory comprehension
L.R. scored 3} 15 on the complex commands (BDAE) and 0} 12 on complex
ideational material on the same test. L.R. stated that she did not understand words
she used to (e.g. activity, cork), and that her premorbid receptive vocabulary was
better than average. Her comprehension of conversational speech was intact. She
refused more in-depth testing of various grammatical structures in the auditory
modality.

Reading
L.R. did not read any material presented to her in a standard way. She directed
stimulus cards to a source of light and turned them, so she could read the words
` through’ the card, as in a mirror. The reading score was 7} 8 (including self-
corrections) in mirror reading and 0} 8 in normal orientation. Errors made during
a backward sentence reading task consisted of letter} word omissions, substitutions
or reversals (b for d, p for g, dran for barn, belf for ¯ed ). L.R. identi®ed all letters of
the alphabet in normal left±right orientation. She was also presented with pairs of
letters. One exemplar of the pair was written regularly, the other in a mirror
manner. When asked to point to a correctly oriented letter, without hesitation she
always pointed to the mirror images. Comprehension of written material, tested in
a similar `mirror ’ fashion, was 6} 10 correct in sentences and paragraphs (BDAE).
Mirror reading after head injury 503

(a)

(b )

Figure 2. ` I have two dogs’ written with both hands simultaneously: (a) centrifugally, (b)
centripetally.

Figure 3. A drawing of a clock. L.R. was asked to set the arms at 10 minutes after 11 o’clock.

Writing
L.R. wrote in a mirror fashion only, using her right hand. A sample of her writing
done on a transparent paper and copied later in both L±R and R ±L orientations (for
easier analysis) is presented in ®gure 1. Written samples contained syntactic but not
spelling errors. Words with irregular spelling (e.g. ceiling, castle, island ), tested on
diåerent occasions, were all spelled correctly.
L.R. was able to copy some letters in regular orientation but had major di¬culty
with letters s, e, and g. Interestingly, since the accident, L.R. claimed that she could
only print and did not produce any cursive writing on demand. Of note is the fact
that writing with her (L) hand took considerably more time than (R)-handed
attempts of the same text (27.5 seconds and 10.18 seconds, respectively). All
experimental tasks were carried out with both hands either simultaneously or
individually, as outlined in the Procedure section. Regardless of the instructions
and hand used, the results were uniformly similar : mirror writing in every instance.
Figure 2 represents the results of her writing a sentence with both hands
simultaneously in (a) centrifugal and (b) centripetal manner. Other writing tasks,
such as writing under the table and on the forehead, produced mirror writing. Also
drawing tasks resulted in mirror images, as the clock in ®gure 3.

Discussion
L.R. presented with a severe and unusual language and speech disorder which
included some features of a post-concussion syndrome (cognitive and personality
changes) and some of aphasia (anomia, syntactic errors in speech and writing,
504 R. Jokel and D. Conn

presence of paraphasias). None of these features, however, could fully account for
the atypical and very complex presentation of L.R.’s language pro®le, the most
striking of which were her mirror reading and writing and ¯uent backward speech
in selected situations. In addition to her language disturbance, in the absence of
neurological correlates, the weakness of her leg was also considered to represent a
conversion disorder. It is important to note that, 1 week prior to her admission, the
Worker’s Compensation Board sent a letter to L.R. stating that ` there are no
physical ®ndings at this time to substantiate the current symptoms that you are
experiencing ’. Disability bene®ts were cut oå.
The features that prompted a more careful look at the aetiology were the
combination of all three mirror phenomena occuring simultaneously, grammatical
errors in L.R.’s spontaneous speech, and the type of mirror writing L.R. used.
There is no report in the extant literature describing the co-occurence of mirror
reading, writing and speech in one person after an acquired disorder. Nor is there
any evidence that the three would have a ` cognitive reason ’ to occur sim-
ultaneously. The connection between the temporal and spatial aspects of speech is
yet to be found. L.R.’s writing was unique and it has not been described in the
literature. Reports in the literature consistently pointed to a R±L direction,
whenever the dominant (R) hand was used (as in L.R.’s case), and each word
beginning with the initial letter. L.R. wrote words from (L) to (R), as all of us do
in English, but every letter was oriented from (R) to (L). In addition to that, she
wrote words beginning with the ®nal letter of each word. The hypotheses
regarding mirror writing presented in the literature become irrelevant in this case
for many reasons. The use of non-dominant hand was not observed beyond
experimental tasks, which is in contrast to the motor hypothesis (Critchley 1926).
Visual (Orton 1928) and directionality (Chia and Kinsbourne 1987) hypotheses
could not be considered because of the way L.R. wrote (from left to right,
reorienting only letters). In fact, some studies provide evidence against spon-
taneous mirror writing with the dominant hand (Kuzuya et al. 1991, Buxbaum et al.
1993).
The most striking and unusual feature of L.R.’s language was her `reversed ’
speech. She claimed that she `read the words as they appear in her head, not minding any
rules ’. Had she followed the orthographic rules strictly, the `reading ’ pattern
would resemble ` surface dyslexia ’, re¯ected in incorrect pronunciation of irregular
words. That was not seen as a feature of L.R.’s speech. She was observed to use
both the orthographic and phonological routes in her backward speech, e.g. she
said [rod] for door, whereas, according to her description of the ` translation ’
process, the expected word would be [rU d]. The reversals were not free of errors
(letter} sound transposition), suggesting that the ` translation system ’ was either
impaired or had not been mastered. When asked about her forward speech, L.R.
said that it was very eåortful, because she needed to translate everything, ` so others
would understand’. Frequent observations of L.R.’s spontaneous interactions
(with other patients) suggested that there was no eåort whatsoever. Interestingly,
L.R. also claimed that `everything other people say sounds backward ’. There is no
support in the literature that this would be possible. This would also go against
what we know about the temporal aspects of speech.
Another noteworthy feature of L.R.’s speech is the word order in forward and
backward sentences. She was not agrammatic, yet her utterances were occasionally
fragmented in an unusual way, uncharacteristic of any aphasic syndrome. Similar
Mirror reading after head injury 505

to W.H., an aphasic patient reported by Maher et al. (1995), L.R. did not appear to
have memory de®cits, phonological processing impairments or de®cits in
processing complex grammatical structures that could account for her failure to
produce syntactic speech, i.e. ` boy the ’. Unlike W.H., no `legitimate ’ disruption
of the functional level of sentence production could be assertained, because L.R.’s
production was inconsistent with any reported pattern of sentence structure
breakdown in pathology such as aphasia. Numerous studies in syntactic
breakdowns would provide support to this conclusion (Pinker 1993, Grodzinsky
1990, Caplan 1994).
Critchley (1928) emphasized the importance of circumstances under which
backward speech occurs. He himself saw three possibilities :

(a) psychotic states : dementia praecox (schizophrenia), post-seizure states, hysteria


(conversion disorder);
(b) mannerism of speech, used deliberately with juxtaposition of syllables ;
(c) deliberate use as a ` cryptic parlance ’ where the literal meaning (although not
obvious) can be easily extracted, as in S. Butler’s ` Erewhon’ (misspelled by the
author himself).

Published cases demonstrate that although a brain insult can result in backward
speech (Cocchi et al. 1986), one does not need a brain injury to e¬ciently speak
backwards (Cowan and Leavitt 1982, Cowan et al. 1982). One condition that seems
to be necessary (in case of orthographic reversals) is clear visual imagery of words.
` To read aloud in a backwards direction is not easy but the reversed delivery of a
sentence `` out of one’s head ’’ must be an extraordinarily di¬cult feat unless one
has a particularly vivid mental concept of the words. In such cases the performance
is a purely volitional eåort’ (Critchley 1928). We are reminded that L.R. was an
accomplished special education teacher, about to complete the requirements for a
PhD degree. It may be possible that, through her work and exposure to the
literature, she became quite familiar with aberrant cognitive behaviours.
One may argue that, since L.R. sustained a head injury, a neurogenic cause is the
only valid aetiology of her behaviour. However, her language pro®le, negative
neuroimaging, normal neurological examination, progressively improving ¯uency
and prosody of backward speech over time, and the delayed appearance of the
backward speech itself, cast doubt on the primary aetiology being neurological.
L.R.’s poor cooperation, her refusals to participate and statements on the level of
task di¬culty (` I can’t do it ’) even before she tried a task, her ability to perform
identical tasks on one day but not the next (written production of the same words),
and subjective observations of L.R.’s spontaneous conversational encounters,
raised the question of the genuineness of her eåorts. Although malingering was
considered, the team did not believe that the patient’s symptoms were intentionally
produced or feigned. It was felt that they represent a conversion reaction to the
trauma.
The diagnosis of conversion disorder is notoriously di¬cult and fraught with
pitfalls. As described earlier, there appears to be considerable overlap between the
development of conversion symptoms and other medical and neurological diseases.
Indeed many patients with a diagnosis of conversion disorder ultimately turn out
to have an ` organic condition ’. Adams and Victor (1993) emphasized the need for
careful history-taking and the performing of a physical and mental status
506 R. Jokel and D. Conn

examination. They note that when one takes into account the time of onset, the
longitudinal history, the manner and attitude of the patient and the absence of signs
and symptoms of other medical and surgical conditions, an accurate diagnosis can
be made in a majority of cases. They also note that the diagnosis of hysteria
(conversion) is often made by the ` discrepancy method ’. This means that the
patient’s symptoms or signs were not deemed to be credible manifestations of
disease based on the clinical experience of the examiner. They do point out,
however, that the examiner must have considerable experience, and that for the
novice many syndromes are incomprehensible.
The DSM-IV criteria for conversion disorder were described earlier in this
paper. We believe that, in spite of the limitations and di¬culties involved in
making the diagnosis, L.R. ful®lled the criteria for this condition.
This is an example of a complex case that was seen on a behavioural neurology
ward. In addition to the unusual type of mirror writing, it was noted during the
sodium amytal test that there was more to this patient’s speech than incom-
prehensible neologisms. This suggests that such cases require detailed and
systematic evaluation of verbatim recording of patients’ productions. Similar cases
should be published to enhance our understanding of why patients like L.R. take
refuge in unusual language behaviours.

Acknowledgements
The authors gratefully acknowledge the eåorts of the staå on the Behavioural
Neurology Unit in assessing and managing this di¬cult case. We are also indebted
to Drs K. Stokes, C. Leonard, L. De Nil and S. Novak for their useful comments
on the manuscript, and to Drs E. Rochon and L. Buxbaum for suggestions in the
initial stages of the project.

Appendix
L.R.’s responses on the Boston Naming Test (include cued responses). } } indicate
responses in backward speech.
1. bed } deb}
2. tree } irt}
3. pencil } lik @nep}
4. house } esuoh}
5. whistle } eltsih}
6. scissors } srokis}
7. comb } mok}
8. ¯ower } rewolf}
9. saw } was}
10. toothbrush } h@surb@htoot}
11. helicopter } retpokAi l}
12. broom } mDrb}
13. octopus } supotko}
14. mushroom } eert}
15. hanger } regnah}
Mirror reading after head injury 507

16. wheelchair } rakli w}


17. camel } lemak}
18. mask } k@sam}
19. pretzel } lertzep}
20. bench } h@hneb}
21. raquet } tekuar}
22. snail } lians }
23. volcano } onaklov}
24. seahorse } lians }
25. dart } worra, trad}
26. canoe } eonak}
27. globe } ebolg}
28. wreath } h@tar @w}
29. beaver } reveab}
30. harmonica apartment house
31. rhinoceros } popih, nrokinu}
32. acorn hat and head but no eye
33. igloo doghouse, dogloo
34. stilts } st@lits}
35. dominoes dice
36. cactus } sa, sakak, satkak}
37. escalator } striats, rotlaksee}
38. harp } prah}
39. hammock outside bed
40. knocker } rU d} decoration
41. pelican } drib} ugly, duck
42. stethoscope } epoksotep}
43. pyramid } sk@ nifs}
44. muzzle dog’s harness
45. unicorn } esroh, @nrokinu}
46. funnel } lenuf}
47. accordion like the other one
48. noose } epor} , hanging rope
49. asparagus ¯ute, } etulf}
50. compass } sap@mak}
51. latch stick
52. tripod compass, tricycle?
53. scroll } harot} , script
54. tongs invisible cubes, spoon
55. sphynx } @xnyf@n}
56. yoke } senrah}
57. trellis sticks on the house
58. palette } murd}
59. protractor } sapmok}
60. abacus } s@daeb}
508 R. Jokel and D. Conn

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