Neuropsychology & psychiatric
disorders
College 1 Introduction
Historical perspective on psychiatry
Before 1800 patients put away in institutions, no doctors where involved.
Impairments and symptoms where not seen as a disease, but as immoral
behavior. Circumstances where terrible. During the French Revolution,
1790 people started getting a different view on psychiatric disorders.
Pinel, a well-known psychologist, started treating people different: morel
treatment. It took till 1860 before universities started researching
psychiatric, patients with psychiatric disorders where labeled as having a
lack of moral behavior. Over time this changed to a neurobiological
perspective, neuropsychological disorders where seen as a disease of the
brain. Kraepelin was one of the first to classify disorders in 1890, he wrote
a classification system: Kompendium, which is nowadays seen as the basis
of the DSM. In 1880 Janet started treating people with hypnosis and
catharsis. In 1890 Freud’s psychoanalysis became popular, more space for
psychosocial treatments. Ten years later in 1900 the biological psychiatry
became popular (ECT and lobotomy). In 1940 chloorpromazine was seen
as the first antipsychotic drugs, this was proof for brain dysfunction. The
introduction of the DSM, another important milestone took place in 1950.
Modern Psychiatry
It is not only the brain that is involved in psychiatric disorders, the
interaction between the brain and the environment is also important (as
seen in schizophrenia in twin studies). The focus is not only on the brain of
patients anymore but also on their development and context. When
looking at treatment it should not only be focused on symptomatic
remission but also on participation in society or leading a fulfilling live.
Patients can consider themselves as recovered when they still have
symptoms. Recovery is not only a lack of symptoms but also the context
and leading a meaningful live. In modern psychiatry psychosocial
treatments have become very popular (for example cognitive behavioral
therapy or cognitive remediation). In 2013 the DSM 5 was released, the
DSM makes categorizations, based on observable symptoms patients are
categorized and given a specific diagnostic label. As a reply on the DSM,
the NIMH came with the RDoC, describes mental disorders from a
neuropsychological perspective. Does not classify but describes on specific
dimensions, for example cognitive or social functioning.
Definitions
Psychiatry: medical specialty concerned with the diagnosis and treatment
of mental illness.
Neurology: medical specialty concerned with the diagnosis and treatment
of disorders of the nervous system (brain, spinal cord and nerves).
,Neuropsychology: psychological specialty concerned with relationship
between behavior, emotion and cognition on the one hand and brain
function on the other.
Historic comparison between neurology and psychiatry: neurology studies
diseases of the brain’s anatomic structure, psychiatry studies diseases of
the mind. Neurology is more about structures of disease, while psychiatry
is more about the functioning of the brain and disease. Neurological
disorders are localizable in the brain while psychiatric disorders are often
not localizable in the brain. In neurology brain areas have often direct
correlations with clinical pathology, in psychiatry these correlations are not
always found. In neurology there are distinct syndromes and disease
entities, demarcated by neuroanatomical findings, in psychiatry there are
unclear disease entities, demarcated by clinical observations. Neurological
is about the organic brain, psychiatry about the psychological brain.
Traditional neuropsychology
Assessment traditionally focusses on determining specific changes in
mental processes after discrete brain lesions. Helped to determine locus of
lesion and gave knowledge on the role of brain areas in mental processes.
The focus is on neurological patients.
How do we see ourselves as neuropsychologists?
Generating hypotheses on underlying mechanisms of symptoms.
Understanding the role of cognitive processes in the etiology and
presentation of psychiatric disorders (biomedical model). Understanding
the clinical, behavioral and phenomenological correlates of
“neuropsychological impairments” Doing individual neuropsychological
assessments (profile of strengths and weaknesses).
How see psychiatrists us: useful but underutilized resource.
Neuropsychologist can establish deterioration in cognitive functioning.
Making differential diagnosis. Facilitating improved outcomes. Psychiatrists
need to recognize cognitive impairments and to understand common
neuropsychological tests.
Assessment questions in psychiatry
What is the DSM 5 label? (Can you make a differential diagnosis?)
Question can only be answered when combined with a broader
neuropsychological assessment.
Will this person be able to go back to school/work? Can be partly
answered, depends on a lot of things. By making a profile of
strengths and weaknesses you can display what might be possible.
Are there cognitive limitations that should be taken into account in
the treatment of this person? Question that can be answered by
making the profile of strengths and weaknesses, and the cognitive
impairments can be seen.
Can you evaluate the effect of pharmacological interventions on
cognitive functioning? Quite often this is possible, see if drugs
treatments result in better cognitive functioning.
, Are the cognitive impairments due to ADHD or drug use? Most often
we can’t, most cognitive impairments can be caused by many
factors.
Please assess cognitive functions
Symptoms/ Examples of cognitive processes
impairments
Hallucinations Imagery
Speech processing
Metacognitive control (eg misattribution of
internal speech)
Delusions Jumping to conclusions
Theory of Mind
Memory
Attention
Anxiety Attention
Memory
Depressive symptoms Attention
Memory
Emotion Recognition
Social Dysfunction Emotion recognition
Theory of Mind
Verbal memory
Impaired insight Executive Functioning
Set shifting
Theory of Mind
Apathy Reward processing
Imagery
By hallucinations it can be hard to distinguish one’s own imagination from
factual information. Speech processing is also involved, they really hear
voices. People with delusions tend to jump to conclusions and have
difficulties with theory of mind. They often memorize and pay attention to
events regarding their delusions, an attentional bias. This is the same for
anxiety and depressive symptoms, patients with depressive symptoms will
tend to see neutral faces as sad faces, a problem with emotion
recognition. This is also seen in social dysfunctioning together with
difficulties with theory of mind, patients don’t really understand what
others think, feel or experience. In Schizophrenia there is a relation
between verbal memory and social dysfunctioning, it is hard to keep track
with social interactions when you don’t remember wat someone said.
Many people with psychotic disorders have impaired insight, they believe
there is nothing wrong at least not with them. Impaired insight is
associated with poor executive functioning, for example set shifting. They
are more rigid can’t really let go of their one perspective. Also, difficulties
with theory of mind. In apathy is seen that patients show a lack of
initiative and show impaired reward processing and have difficulties with
visioning themselves in specific situations.
Traditional interpretation errors (especially in psychiatry)
, Neuropsychological tests measure specific functions, and poor
performance on a single test indicates a specific neuropsychological
deficit.
If a patient shows poor performance on a verbal memory test, it
would be an interpretation error to conclude that the patient has
memory problems. It could be the case that the patient had
difficulties with the instructions and thus had poor performance on
the test.
Abnormal neuropsychological test performance indicates specific regional
brain dysfunction. Never a one to one relationship
If a patient’s scores poor on a test of executive functioning it is not
necessarily the case that the frontal cortex is dysfunctional. It might
be attentional problems; it is not a one to one relationship.
Hypoactivity during function imaging procedures with cognitive activation
tasks suggest regional brain dysfunction
When there is no activity found in a certain part of the brain it can’t
be said that this part of the brain is dysfunctional. Sometimes when
people show hypoactivity they simple don’t try. Assuming brain
dysfunction is wrong.
Interpretation errors in Neuropsychiatry
Directly linking brain areas and disorders/personality/sexual orientation:
neophrenology
For example, Swaab how linked homosexuality to a part of the brain
that wasn’t functional, he linked this part to homosexuality. These
complex things, even if there is an association is found never
depends on single brain areas.
Making a psychiatric diagnosis based on neuroimaging studies
Cognitive impairments aren’t specific, there is no specific cognitive
pattern. Neither is there a specific brain area that can be linked to
mental disorders. ADHD or Schizophrenia aren’t seen under a
scanner like MRI.
Reductionism: psychological conditions are brain disorders associated with
a state of chemical imbalance
Patients with depressions say they lack serotonin, they recall they
are depressed because they lack a chemical substance in their
brain. They do, but this is way too simple, context and environment
also play an important role.
Assuming an association between functional impairments and
neuropsychological impairment is disorder-specific
There is no specific association between functional impairment,
neuropsychological impairment and specific disorders. Poor
performance on a specific test can’t automatically indicate a specific
disorder.
Assuming neuropsychological dysfunction causes such functional
impairments.
If a correlation between a neuropsychological dysfunction and a
functional outcome, it is not directly clear that the
neuropsychological dysfunction causes the functional impairment, it
can also be the other way around. For example if emotion perception
