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Summary B&C2: Clinical Neuropsychology
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Clinical Neuropsychology (B&C 2)CHAPTER 2: Neuropsychology in practice
Neuropsychological tests
o Diagnostic cycle
1. Complaint analysis stage: patient and informants are interviewed
2. Problem analysis stage: problem analyzed through different tests
3. Diagnosis stage: diagnosis made based on previously gathered information
4. Indication-for-treatment stage: need for further diagnostics/options for treatment is
examined
o Start with well-defined referral question
During examination, might formulate additional/broadened questions to consider
possibility of other disorders
o Interviewing patient: patient provides info about
Current complaints, symptoms, and its progression
Educational, social, professional, and medical background
- Gives first impression of patient’s cognitive abilities and behavior
- Builds working relationship
- help select appropriate tests and questionnaires
- helps in diagnosis because may be discrepancy between what patient says and what
behavior is exhibited
- Symptom validity test can signal underperformance/over-reporting symptoms
o Interviewing informant:
Because many patients not able to provide reliable info
But info informant also subjective and might not be representative of actual situation
In absence of patient (not feeling uncomfortable)
Emotional overload informant over-reporting complaints and changes
Acceptance problems minimize the complaints
o Observation
Recording interview, tests, outside examination room
Observations free from interpretations (specific observation as crying can be result of
many factors)
Essence: see attitude and manner with which patient conducts test
Gives info about cognitive functioning
Test score and way in which patient completes test is in concordance
Poor performance not always indicate cognitive disorder
o Test and questionnaires
Multiple tests, always same for every patient
Factors to consider for which tests to choose
- Reliability
- Validity
- Normative data
- Discriminative power
- Availability of parallel version
Computerized testing: high level standardization, accurate recording and time saving
(especially measures attention and reaction time), but lack qualitative observations
and flexibility, and can lose significance
Achieve standardized conditions
- All patients same understanding of purpose and asked to do
- Assessing personality traits, coping styles, mental complaints because it not only affects
performance, it can determine neuropsychological problems in daily functioning
o Interpretation
All gathered data integrated
, Abnormal? Depends on if test results are
- reliable, valid, truly reflect level of cognitive/emotional functioning
- what is cut-off point
- normative data (how/where determined)
- qualitative aspects involved (e.g. types of errors and strategies)
- what do we learn from observations and complaints?
- Prevalence?
- Type of impairment expected within specific disorder?
Test doesn’t indicate cognitive disorder, does not mean there is no brain
injury/disorder!
Abnormal performances don’t always indicate cognitive disorders
Setting of test taken into account (influences patient positively/negatively)
Complaints may not be equated to disorders
Findings considered independently of whether they confirm/oppose hypothesis
Differential diagnosis (check for alternative explanations)
o Reporting
Reported verbally and in written form
Written reports for referrer
Verbal reports take place with patient (and multidisciplinary team/referrer)
Content report must be discussed with patient before reporting to further instances
Diagnosis not yet definite and tests must be done don’t inform patient about
neuropsychological conclusions; results can be discussed, not possible cause or
diagnosis
Sensitivity: likelihood that test will identify person with a disorder as ‘disturbed’.
Specificity: likelihood that test will identify person without disorder as ‘not disturbed’
neuropsychologists often choose test with high sensitivity (because cognitive disorders may not be
missed)
Prevalence: number of cases of specific disorder that occurs within particular number of people
Incidence: number of new cases of disorder that occurs within specified period
Reliability: accuracy of instrument
o Test-retest reliability: yielding same results when taken at different times by same patient
(correlation coefficient)
o Interrater reliability: correspondence between results of same test administered by various
researchers (Cohen’s kappa)
Validity: whether test measures what is supposed to measure.
o Face validity: extent to which test initially measures what it is supposed to measure
o Content validity: extent to which test is representative of topic that is to be measured
o Construct validity: extent to which result of test reflects cognitive function that is being
assessed
o Criterion validity: extent to which a test can predict performances of a patient about an
external criterion
Predictive validity: how accurately a test predicts behavior
Concurrent validity: difference between neuropsychological test and other tool that
aims to measure same criterion
o Ecological validity: extent to which test predicts the patient’s daily functioning
Ongoing discussion: whether neuropsychological tests are ecologically valid; might
be too far from day-to-day reality.
- Only because a test measures what it is supposed to measure (face validity), doesn’t mean
it predicts patient’s function in everyday life (ecological validity)
Confounding factor: element that affects performance on test but does not fall within measurement
objective.
o Can result in performances appear to resemble those seen with damaged brain functioning
o Need to be included in interpretation of test results
, o Confounding factors found switch to less conventional methods/observe in natural
environment
Underperformance incorrect diagnosis adverse consequences for patient and
society
= performance is lower than what they would achieve with normal effort
- Caused by being extremely tired, nervous, complaints/anxiety, simulates/exaggerates
cognitive complaints
- Should be considered when patient performs better on challenging tasks than on easy
ones, and if striking discrepancy between behavior and test performance occur or if
patient’s complaints are not in accordance with severity of disorder
- Sometimes intentional; in forensic neuropsychology could reduce prison sentence
TOMM (mpc test; score significantly below level achieved by chance intentional)
Symptom validity tests: can identify underperformance
o Appear to be difficult and measuring cognitive function, but it is very easy and require
processes that are intact in all patients with brain damage
o Underperformance no conclusion can be made; look at results and patient for possible
explanations for underperformance
Neuropsychological treatment
o Professional health care institutions for neuropsychologists
Hospitals
Rehabilitation centers
Mental health care
Residential homes, nursing homes, supported housing
Forensic institutions
Conclusion
o Neuropsychology evaluates
Behavioral effects of a disease
Gives advice to close ones
Find most appropriate treatment
o Non-stressful and non-intrusive assessments somatic/psychiatric diagnosis
o Integrate tests, observation, and interviews
CHAPTER 21: The Parkinson’s spectrum
Clinical picture
o Motor symptoms
1. Lack of movement/slowness
Akinesia: movement cannot be started immediately after commanding it
Hypokinesia: decreased bodily movement, manifested as limited facial expression
and loss of automatic movements
Bradykinesia: making slow movements, sudden stiffening of movement
(freezing), occurs late
Rapid fatigue
2. Rigidity
Cogwheel phenomenon: Tightness and sore muscles resulting from stiff
movements
Micrographia
Hypophonia: limited vocal volume
Small, shuffling steps
3. Rest tremor
Only occur when body part doesn’t move, can barely be suppressed
4. Postural instability
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