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Summary SV Clinical neuropsychology
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This summary contains chapters of the book 'Fractured Minds' and the additional reading material (articles) for the third year's course Clinical Neuropsychology
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Clinical neuropsychology1 Introduction to clinical neuropsychology
Definition of clinical neuropsychology and its aims
Clinical neuropsychology is the study of human behaviors, emotions, and thoughts and how they
relate to the brain (particularly the damaged brain). It has applied aims and an academic aim. Applied
aims: learning more about neurological disorders and diseases so that we can more accurately and
usefully diagnose, treat, and rehabilitate people who suffer such disorders. And ultimately find ways
to prevent their occurrence. Academic aim: learn more about how the undamaged or ‘normal’
human brain and mind work by carrying out experiments on brain-damaged people.
Relationship of clinical neuropsychology to other disciplines
Continuum with brain at one end (neurology) and mind at the other (cognitive psychology).
Neurology: study of the medical aspects of central nervous system disorders and
treatments. More concerned with clinical symptoms and signs.
Cognitive psychology: aim is to understand the workings of the human mind by analyzing
the higher cognitive functions and their components.
Cognitive neuropsychology: concentrates on the detailed analysis of higher functions, often
using similar paradigms to those used in cognitive psychology, but it studies brain-damaged
patients rather than ‘normals’. It is less interested than clinical neuropsychologists where
the damage is and how it might be related to the impairment. Not interested in brain
pathology per se, but only as a means to the end of understanding the workings of the
normal mind.
Clinical neuropsychology: also called behavioral neurologists. Has a neurological interest in
brain pathology and the resulting symptoms and a psychological interest in the analysis of
higher cognitive functions, both to understand the workings of the normal mind and to
develop better rehabilitation methods for patients.
CT + MRI: visualize the anatomic structures and damage in the living brain.
PET + fMRI: visualize changing metabolism of the working brain.
Functional neuroanatomy
Gross structure of the brain
3 parts: cerebral hemispheres, cerebellum and brain stem.
Lateral = from the side. Medial = split down the middle from front to back.
Brain stem: 4 parts: medulla oblongata, pons, midbrain, and diencephalon (thalamus
+hypothalamus). It controls respiration, cardiovascular function and gastrointestinal
function.
Cerebellar hemispheres: at base of cerebral hemispheres. Controls motor coordination,
muscle tone and balance.
Cerebral hemispheres: covered by cerebral cortex/grey matter. The ‘hills’ of cortex are
called gyri, and the ‘valleys’ are called sulci.
o White matter: layer below cortex: axons that connect nerve cells to the rest of the
brain.
o deep within the hemispheres lays the basal ganglia.
, o Longitudinal fissure: separates left and right hemisphere
o Central fissure: separates frontal from parietal lobe.
o Lateral fissure: separates temporal lobe from frontal and parietal loves.
o Corpus callosum: connection between hemispheres.
Recticular formation (RF): controls overall arousal level of the cortex. Sends impulses to nuclei in the
thalamus. Thalamus: relay center for motor pathways, many sensory pathways and RF. On reaching
the thalamus, the impulses are relayed to the cerebral cortex, where they influence the level of
mental alertness or sleep.
Limbic system: involved in emotion, motivation and memory
Amygdala, hippocampus: medially temporal lobes
Cingulated gyrus: medial surface frontal and parietal lobe
Deep midline structures (incl. mamillary bodies).
The brain has 3 coverings: menignes. From outside to inside: dura mater, arachnoid mater and pia
mater. Subarachnoid space is the space between the arachnid and pia mater and is filled with
cerebrospinal fluid (CSF). Inflammation of the menignes is called meningitis and causes stiff neck.
Ventricles: lakes of CSF deep in hemispheres. Hydrocephalus: when a small aperture between
ventricles becomes blocked, causing increasing intracranial pressure.
The cerebrovascular system involves two pairs of cerebral arteries: the internal carotid arteries,
which supply the anterior parts of the brain, and the vertebral arteries, which supply the posterior
parts of the brain. The two internal carotid arteries enter the skull and ascend on either side of the
optic chiasm, where ach artery branches to form the anterior cerebral arteries (ACA) and middle
cerebral arteries (MCA), one set in each hemisphere. The MCA branches to form the striate arteries,
which supply the deeply situated internal capsule, the main passageway for the fiber tracts between
the motor cortex and the spine (the corticospinal tract). The striate arteries are vulnerable to
blockage, resulting in damage to the corticospinal arteries and subsequent paralysis of the opposite
side of the body.
The paired vertebral arteries enter the skull at the point where the spinal cord becomes continuous
with the brain stem and join to form the single basilar artery on the undersurface of the brain stem.
Then divides to form paired posterior cerebral arteries.
The internal carotid and vertebral arterial systems are linked at the base of the brain, forming a ring
of vessels lying in the subarachnoid space, the circle of Willis. If one of the main arteries becomes
blocked, the blood can pass around the circle to reach the deprived area. The circle of Willis is a
frequent site of weakening on the artery wall, called aneurysms. If an aneurisym bursts, it expels
blood around the brain in the subarachnoid space, causing a subarachnoid hemorrhage. A blockage
in a vessel can cause a stroke.
Cerebral cortex
Cortical zones
By dividing the cerebral hemispheres into primary, secondary, and tertiary cortical zones, the
anatomical-functional relationships of the cortex can be conceptualized. The parietal, temporal and
occipital lobes lying behind the central sulcus constitute the posterior cortex and are involved mainly
in a person’s awareness of what is happening in the world. Each of these lobes can be divided into
three zones.
Primary zones: primary projection areas in which incoming sensory information is projected
to sense –modality-specific neurons. Primary sensory cortex is in the parietal lobe, the
primary zone of the temporal lobe is concerned with sounds, and the primary zone of the
, occipital lobes represents specific parts of the visual field. Damage to specific areas of the
primary cortex results in highly specific deficits of sensation in the topographically related
body part or sense organ.
Secondary zones (association cortex): lie adjacent to the primary zones. Receive the
modality-specific information from their primary cortex and integrate it into meaningful
wholes. Damage: inability to perceive or comprehend what one is touching or hearing or
seeing.
Tertiary zones: lie at the inner borders of each lobe so that the parietal, temporal, and
occipital tertiary zones overlap. Modality specificity disappears, and integration of
information across sense modalities occurs. Damage: complex higher cognitive disorders
that involve transmodel integration (e.g. writing to dictation). Also links with limbic system
(involved with emotion and memory’).
Frontal lobes: concerned mainly with acting on knowledge relayed to the posterior part of the
cerebral cortex from the outside world. 3 zones:
primary zone (motor strip): parallels the sensory strip in that each side of the body is
mapped topographically onto the primary motor strip of the opposite hemisphere.
Secondary zone (premotor cortex): mediates the organization of motor patterns.
Tertiary zone (prefrontal cortex): involved in executive functions. Has rich connections with
the limbic system, so the prefrontal lobes are intimately involved with mood, motivation,
and emotion.
Cortical lobes
All three posterior lobes (parietal, temporal and occipital) are involved in the awareness, perception,
and integration of information from the outside world, although their connections with the limbic
system ensure that the way the world is experienced is influenced by the individual’s mood,
motivation and past experiences.
Parietal lobe: tactile sensations, position sense, and spatial relations.
o Left parietal lobe: bias toward sequential and logical spatial abilities (details within a
pattern).
o Right parietal lobe: involved with the holistic appreciation of spatial information.
Temporal lobes: concerned with auditory and olfactory abilities. Also integrating visual
perceptions with other sensory information. Connections with hippocampus allow the
integration of emotion and motivation with the sensory information relayed from the
outside world to the posterior lobes of the hemispheres.
o Left temporal lobe: verbal and sequential functions. Language comprehension area,
and new verbal learning and memory.
o Right temporal lobe: nonverbal functions (interpretation emotional voice tone).
Occipital lobes: visual lobes. Mediate sight, visual perception and visual knowledge. Cortical
blindness: unable to see although the eyes function normally. Visual agnosia: unable to
recognize what one is seeing (but can describe the object).
o Left occipital lobe: visual language functions (reading).
o Right occipital lobe: visually judging the orientation of lines or objects in space.
Frontal lobes: concerned with motor functions and executive functions. Left frontal lobe
includes speech area Broca’s area. Prefrontal lobes are integrated with emotional and
motivational states via the cingulate cortex (limbic system), which forms the medial parts of
the frontal lobes. The functional verbal-nonverbal division between the left and right
prefrontal lobes is less marked than in the posterior lobes.
, Functional systems
Simple motor and sensory functions, and even some more complex perceptual functions, are
mediated by a particular group of neurons; therefore, damage to these neurons results in an
unambiguous deficit. Many of our higher cognitive functions, such as reading or memory, are,
however, the result of complex functional systems, composed of a number of different brain areas
working together to produce a behavior. Luria proposed that in terms of double dissociation, damage
to area A will result in the impairment of a factor or subcomponent a, and all functional systems that
include this factor will suffer. If the patient can find a new way to reach the same endpoint while
avoiding the necessity to include the impaired subcomponent, then recovery of function is possible.
Disconnection syndrome
A number of disorders are thought to result from an anatomic disconnection between two cortical
areas. E.g. ideomotor apraxia: unable to perform skilled movements to verbal command but can
perform than spontaneously. Due to damage to the fiber connection between the language
comprehension area in the posterior left temporal lobe and the motor association cortex in the left
frontal lobe. Experiments with split-brain subjects who have had the corpus callosum cut as a
treatment for epilepsy have produced many examples of a ‘pure’ disconnection syndrome. E.g. show
something right visual field projected to left hemisphere patient can name the objet. Show
something left visual field projected to right hemisphere patient cannot name it, but can point to
it.
Neuropsychological terminology
A syndrome refers to a group of symptoms that characteristically occur together after brain damage.
Phasia: speech disorder. Graphia: writing. Lexia: reading. Praxia: to work or perform
purposeful actions. Gnosia: to know.
‘a-’: function is completely absent. Dys-: partial impairment.
Prosopagnosia: inability to recognize faces.
Anosognosia: deny knowledge (e.g. patient who denies she has paralyzed limbs). Visual
anasognosia = patient denies that he is blind.
Contralesional and contralateral: impairments (or body parts) and lesions that are opposite
each other. E.g. a paralyzed right arm is caused by a lesion in the contralateral (left) motor
strip.
Assumptions that underlie clinical neuropsychology
The study of brain-damaged patients to understand the workings of the normal brain and mind relies
on two important assumptions. The first is that the brain of the patient was normal before the brain
damage. the second assumption underlying both cognitive and clinical neuropsychology experiments
is that we can generalize about brain-behavior relations from one ‘normal’ human to another. The
main criticism of this assumption is the evidence that not all patients with a lesion to a specific area
of the brain suffer the same impairments. the most obvious generalization is that the left cerebral
hemisphere is dominant for speech in most people. Making generalizations in the case of children is
more difficult, as the brain develops functions at different rates as the child grows older.
Focal lesions and diffuse brain damage
A focal lesion is damage restricted to a circumscribed area of the brain. Lesion is a general term to
describe any type of focal brain damage. infarct or infarction refers to any area of dead brain. The
most common cause of a focal lesion is a stroke (blockage). Focal lesions can also be caused by a
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