English summary of the first 8 chapters of the book Neuropsychological Assessment by Lezak (5th edition). For the subject Adult and Old Age: Theory and Assessment
Extensive Lecture summary from the course Diagnostics in Clinical Neuropsychology
Summary literature for the course 'Diagnostics in Clinical Neuropsychology'of UL: fifth edition of the book Neuropsychological Assessment by Lezak, Howieson, Bigler, & Tranel
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Universiteit Leiden (UL)
Psychologie
Adult & Old age clinical neuropsychology
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Neuropsychological Assessment – Summary
1. The practice of neuropsychological assessment
- When doing assessments, clinical neuropsychologists typically address a variety of questions of
both neurological and psychological import
Examination purposes
- Any of six different purposes may prompt a neuropsychological examination
1. Diagnosis. Neuropsychological assessment can be useful for discrimination between
psychiatric and neurological symptoms, identifying a possible neurological disorder in a
nonpsychiatric patient, helping to distinguish between different neurological conditions,
and providing behavioral data for localizing the site – or at least the hemisphere side – of a
lesion. Screening is another aspect of diagnosis.
2. Patients care and planning. The neuropsychologist has the responsibility to describe the
patient as fully as necessary for intelligent understanding and care. Descriptive evaluations
may be employed in many ways in the care and treatment of brain injured patients. In
many cases the neuropsychological examination can answer questions concerning patients’
capacity for self-care, reliability in following a therapeutic regimen not merely the ability to
drive a car but to handle traffic emergencies, or appreciation of money and of their
financial situation. Careful reporting and explanation of psychological findings can do much
to allay the patient’s anxieties and dispel confusion
3. Treatment -1: Treatment planning and remediation. Today, much more of the work of
neuropsychologists is involved in treatment or research on treatment.
4. Treatment-2- Treatment evaluation. With the ever-increasing use of rehabilitation and
retraining services must come questions regarding their work. Neuropsychological
evaluation can often best demonstrate the neurobehavioral response – both positive and
negative – to surgical interventions or brain stimulation. Testing for drug efficacy and side
effects also requires neuropsychological data
5. Research. Neuropsychological assessment has been used to study the organization of brain
activity and its translation into behavior, and to investigate specific brain disorders and
behavioral disabilities
6. Forensic neuropsychology. Neuropsychological assessment undertaken for legal
proceedings has become quite commonplace in personal injury actions in which monetary
compensation is sought for claims of bodily injury and loss of function. In criminal cases, a
neuropsychologist may assess a defendant when there is reason to suspect that brain
dysfunction contributed to the misbehavior or when there is question about mental
capacity to stand trial
The multipurpose examination
- Usually a neuropsychological examination serves more than one purpose.
The validity of neuropsychological assessment
- Ecological validity typically refers to how well the neuropsychological assessment data reflect
everyday functioning, or predict future behavior or behavioral outcomes.
Page 1 of 83
, 2. Basic concepts
Examining the brain
- “If our brains were so simple that we could understand them, we would be so simple that we could
not.”
- The distinctive character of neuropsychological assessment lies in a conceptual frame of reference
that takes brain function as its point of departure. A behavioral study can be considered
‘neuropsychological’ as long as the questions that prompted it, the central issues, the findings, or
the inferences drawn from the findings, ultimately relate to brain function
Laboratory techniques for assessing brain function
- Some of the earliest instruments for studying brain function that remain in use are
electrophysiological. These include electroencephalography (EEG), evoked and event-related
potentials (EP, ERP), and electrodermal activity.
- Magnetoencephalography (MEG), the magnetic cousin of EEG that records magnetic rather than
electrical fields, has also been used to examine brain functions. As MEG can have a higher
resolution than EEG, it can more precisely identify the source of epileptic discharges in patients
with a seizure disorder. MEG however is more expensive
- Electrodermal activity (measured as skin conductance response (SCRI)) reflects autonomic nervous
system functioning and provides a sensitive and very robust measure of emotional responses and
feelings
- Other methods are known as ‘functional brain imaging’
o Computerized tomography (CT)
o Magnetic resonance imaging (MRI)
o Positron emission tomography (PET)
o Single photon emission computed tomography (SPECT)
o Functional magnetic resonance imaging (fMRI) capitalizes I he neural phenomenon that
increasing neuronal activity requires more oxygen; the amount of oxygen delivered by
blood flow actually tends to exceed demand, creating a ratio of oxygenated to deoxygenated
blood that is known as the BOLD signal which can be precisely and accurately measured
and quantified. It is a popular method for investing all manner of psychological processes
such as time perception, emotional processing, etc.
- A CT might be best suited for acute head injury when skull fracture and/or bleeding are suspected
whereas MRI might be the study of choice in the chronic stages of head injury, when the clinician is
concerned about white matter integrity
- PET applications are limited by their dependence on radioisotopes that have a short half-life and
must be generated in a nearby cyclotron. Cost and accessibility are other factors
Neuropsychology’s conceptual evolution
- Neuropsychology’s historical roots go deep into the past
Concerning terminology
- Praxis: in the strict sense, it refers to motor integration used to execute complex learned
movements
o Apraxia: dysfunctions due to a breakdown in the direction or execution of complex motor
acts
Dimensions of behavior
- Behavior may be conceptualized in terms of three functional systems
o Cognition: the information-handling aspect of behavior
o Emotionality: concerns feelings and motivation
o Executive functions: have to do with how behavior is expressed
Page 2 of 83
,Cognitive functions
- The four major classes of cognitive functions have their analogues in the computer operations of
input, storage, processing and output
o Receptive functions: involve the abilities to select, acquire, classify and integrate
information
o Memory and learning: refer to information storage and retrieval
o Thinking: concerns the mental organization and reorganization of information
o Expressive functions
o The means through which information is communicated or acted upon
- Generally speaking, within each class of cognitive functions a division may be made between verbal
and nonverbal functions, where ‘verbal’ refers to functions that mediate verbal/symbolic
information and ‘nonverbal’ refers to functions that deal with data that cannot be communicated in
words or symbols, such as complex visual or sound patterns
Neuropsychology and the concept of intelligence: brain function is too complex to be communicated in a
single score
- One of neuropsychology’s earliest findings was that the summation scores (e.g. IQ scores) on
standard intelligence tests do not bear a predictable direct relationship to the size of brain lesions.
When a discrete brain lesion produces deficits involving a broad range of cognitive functions, these
functions may be affected in different ways
- Another major problem with a construct as Spearman’s g, is that it cannot account for theories of
multiple intelligences and, in particular, fails to incorporate emotional abilities and social
intelligence
- Knowledge of the complexities of brain organization and brain dysfunction makes the unitary
concept of intelligence essentially irrelevant and potentially hazardous for neuropsychological
assessment.
- It refers to a derived score used in many test batteries designed to measure a hypothesized general
abilities. Composite IQ scores are often good predictors of academic performance, which is not
surprising given their heavy leading of school-type and culturally familiar items. For
neuropsychologists, however, composite IQ scores represent so many different kinds of conflated
and confounded functions as to be conceptually meaningless
- Derived scores based on a combination of scores from two or more measures of different abilities
potentially results in loss of important information
Classes of cognitive functions
Receptive functions
- Entry of information into the central processing system proceeds from sensory stimulation, i.e.
sensation, through perception, which involves the integration of sensory impressions into
psychologically meaningful data, and thence in memory
- Sensory reception
o Sensory reception involves an arousal process that triggers central registration leading to
analysis, encoding, and integrative activities
- Perception and the agnosias
o Perception involves active processing of the continuous torrent of sensations as well as
their inhibition or filtering from consciousness. This processing comprises many successive
and interactive stages. The perceptual functions include such activities as awareness,
recognition, discrimination, patterning, and orientation.
o Impairments in perceptual integration appear as disorders of recognition, classically
known as the agnosias (literally, no knowledge)
Associative agnosia: failure of recognition that results from defective retrieval of
knowledge pertinent to a given stimulus. The patient is unable to recognize a
stimulus despite being able to perceive the stimulus normally
Apperceptive agnosia: a failure of the integration of otherwise normally perceived
components of a stimulus. The patient fails to recognize a stimulus because the
patient cannot integrate the perceptual elements of the stimulus even though those
individual elements are perceived normally
Page 3 of 83
, Memory
- Central to all cognitive functions and probably to all that is characteristically human in a person’
behavior is the capacity for memory, learning and intentional access to knowledge stores, as well as
the capacity to ‘remember’ in the future
- Amnesia (literally, no memory)
- Anterograde (involving new experiences)
- Different memory systems
o Declarative (explicit) memory: involves a conscious and intentional recollection process
and refers to information that can be brought to mind and inspected in the ‘minds eye’, and,
in that sense, ‘declared’
- Stages of memory processing
o Registration or sensory memory
Iconic memory: a fleeting visual image lasting up to 200msec
Echoic memory: auditory ‘replay’ lasting up to 2.000msec
o Short-term memory
Immediate memory (the first stage of short-term memory): temporarily holds
information retained from the registration process. Short-term memory may be
equated with simple immediate span of attention. It serves as a limited capacity
store from which information is transferred to a more permanent store and also as
a limited capacity retrieval system
Rehearsal: any repetitive mental process that serves to lengthen the duration of a
memory trace. It increases the likelihood that a given bit of information will be
permanently stored but does not ensure it
Memory that lasts from an hour or so to one or two days but is yet to be fixed as
learned material in long-term storage
o Long-term memory (secondary memory): the acquisition of new information and refers to
the organism’s ability to store information. Memories are not stored in a single local site;
rather, memories involve contributions from many cortical and subcortical centers
- Recent and remote memory are clinical terms that refer, respectively, to autobiographical memories
stored within the last few hours, days or weeks, or even months and to older memories dating from
early childhood
- Amnesia
o Transient global amnesia: the amnesia is limited to a fairly discrete period while memories
before and after that period remain intact
o Anterograde amnesia: the inability to acquire new information normally. It is the most
typical memory impairment that follows the onset of neurological injury or conditions that
is tantamount to impaired learning. It is a hallmark symptom of Alzheimer’s disease
o Retrograde amnesia: loss of memory for events preceding the onset of brain injury, often
due to trauma
- Recall: involves an active, complex search process
- Recognition: when a stimulus triggers awareness
- Episodic memory: refers to memories that are localizable in time and space (e.g. first day in school)
- Semantic memory: ‘timeless and spaceless’ knowledge (e.g. the alphabet)
- Source memory or contextual memory: refers to knowledge of where or when something was
learned
- Prospective memory: the capacity for ‘remembering to remember’
- Future episodic memory: we are able to revisit our past experiences through our memories. The
creation of future scenarios requires drawing upon past experiences to guide one’s representation
of what might happen in the future
Page 4 of 83
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