Acquired cognitive deficits can present themselves in many ways and can be confusing for the people affected as well as for those around them. This case illustrates the use of cognitive models for understanding an unusual neuropsychological syndrome that was not initially apparent.

Initial meeting and background

We first met Malcolm at Headway House in Cambridge in 1991. At that time his difficulty with the localization of objects was thought to be due to poor eyesight. We were starting a memory group there and wanted to administer a number of tests to the people coming to the group. One of the tests was the Raven's Standard Progressive Matrices (Raven, 1960). This test requires the person being tested to look at a matrix with a piece missing and then choose one of six or eight stimuli at the bottom of the page that will complete the matrix. Although Malcolm was articulate and had a fund of general knowledge, it was immediately obvious that he had difficulty with the Raven's test. He appeared to have problems seeing the missing part in the matrix and he could not point accurately to the stimuli at the bottom of the page. He frequently pointed to a blank part of the page or else placed his finger over two adjacent stimuli. Given that one of the major characteristics of Balint's syndrome (Balint, 1909) is an inability to localize in space (optic ataxia), we wondered if that was the explanation for Malcolm's poor pointing ability.