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Clinical Neuropsychology - Extensive summary of all lectures (english)
- Instelling
- Universiteit Leiden (UL)
Clinical Neuropsychology - Extensive summary of all lectures (english)
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Lectures Clinical NeuropsychologyLecture 1 – Introduction to Clinical Neuropsychology
Clinical neuropsychologists are interested in the relation between brain and behavior.
Examples of brain disorders are genetic and neurodevelopmental disorders (like Down’s
Syndrome, ADHD, Dyslexia), neurointoxication (alcohol and drugs) and
neurodegeneration (Alzheimer, Parkinson, MS). Behavioral consequences can be in three
domains: neurocognitive functioning (memory, attention, language), mood (mainly in the
beginning of the disease as a result of brain damage, or secondary because living with a
disease can cause mood disorders → depression, anxiety), and behavior (agitation,
irritability, pathological laughing or crying). The type of (cognitive) consequences differs per
brain disease.
The DSM-5 is used to diagnose mental disorders. Clinical neuropsychologists are mainly
involved in chapter 17 – Neurocognitive disorders – to diagnose whether there is a
neurocognitive disorder, how severe it is, and what the prognosis will be. They are also
involved in the treatment of neurocognitive disorders.
According to the DSM-5, there are six neurocognitive domains:
• Complex attention → sustained attention, divided attention, selective attention, and
processing speed.
• Perceptual-motor function → visual perception, visuoconstructional reasoning, and
perceptual-motor coordination.
• Language → object naming, word finding, fluency, grammar and syntax, receptive
language.
• Executive functioning → planning, decision making, working memory, responding
to feedback, inhibition, and flexibility.
• Learning and Memory → free recall, cued recall, recognition, semantic and
autobiographical long-term memory, and implicit learning.
• Social cognition → recognition of emotions, Theory of Mind, and insight.
Clinical neuropsychologists have developed many tests to test these different domains..
Neuropsychologists are also interested in mood (depression and anxiety) and behavior.
Different psychological symptoms, like anxiety, depression, delusions, hallucinations,
irritability, disinhibition, and altered sleep/wake can influence the results that measure
neurocognitive domains.
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,There is a distinction between the symptoms, what type of disorder it is, and what kind of
disability it causes in daily life. The patient will come to the neuropsychologist, and the first
thing they tell is about the limitations in their daily life, e.g., ‘I am easily distracted’. The
psychologist has to deduct from this description what kind of symptom it is. In this case, it
would be ‘attentional deficit’. The psychologist must be able to listen to the story of the
patient and the caregiver, and deduct from that. It is not always as easy, because memory
problems can be caused by attentional deficits.
Neuropsychological assessment – Indications
There are a couple of reasons why a person would apply for a neuropsychological
examination. In most cases they are referred by the GP, a neurologist, or a rehabilitation
doctor. In some cases, the patient or their family might want a neurological examination. A
logical indication is that the patient or those close to the patient complain about
(neuro)psychological functioning. Also, questionable age-related forgetfulness is an
indication. Whether (neuro)psychological development is normal or pathological is a factor.
In case of brain damage, neuropsychological profiling can be done to determine the
remaining capacity. You can monitor neuropsychological progress before and after an
intervention (e.g., pharmacological), with neuropsychological assessment. It is also used to
determine the relative role of neurological vs. psychological factors. Lastly clinical
neuropsychologists are involved with formulating indications and goals for
neuropsychological rehabilitation. It could also be the case that people exaggerate their
problems to get more insurance or less severe punishment (forensic).
Other complaints that people might have: less concentration, forgetfulness/disorientation,
less word finding abilities, less multitasking, slowed thinking and action, less able to organize
and anticipate, less able to read, write and less arithmetic abilities, less able to dress, cook and
do self-care. Also more depressed, apathetic, uninhibited, having a changed personality,
being easily tired, having pain or other somatic complaints.
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,The British Psychological Society report (on Brightspace) strengthens the role of clinical
neuropsychologists in an interdisciplinary team. The role of clinical neuropsychologists
consists of:
• Specialized diagnostic assessment of patients presenting with cognitive or
behavioral change in the context of actual or suspected neurological illness or injury.
• Reporting on the indications that a given disorder is present, the degree to which
cognitive functions have been affected, and the likely outcome of the disorder
(prognosis).
• On the basis of neuropsychological assessment, a diagnosis, prognosis and
recommendations for treatment and support will be given.
Methods: behavioral observation, an extensive anamnesis, and neuropsychological
tests/questionnaires.
Treatment: they provide treatment for the cognitive, mood, and behavioral problems
resulting from the actual or suspected neurological illness or injury. Different methods for
treatment are: psychoeducation, function training, strategy training, CBT, system therapy,
and lifestyle adjustment.
Alzheimer’s disease
Alzheimer’s disease is a neurodegenerative disorder, there is a progressive loss of neurons
in the brain. It starts with atrophy in the medial temporal areas of the brain (hippocampus).
The hippocampi are the first areas to be affected → memory problems. Later on, there is
more global atrophy.
The pathological hallmarks of Alzheimer’s disease are the plaques and the tangles. Amyloid
plaques, which are an abnormal deposition of the amyloid protein, between the brain cells.
There are tangles as well. These tangles are made from phosphorylated tau proteins.
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, This accumulates within the neurons. In both cases, the communication between neurons is
hampered. This damages the neurons. It also causes atrophy in the brain.
There are many other processes going on, like inflammation of the brain, vascular
dysregulation, synaptic disfunction. But the main pathological hallmarks are the plaques
and the tangles.
The disease consists of cognitive deterioration (starting with memory problems). To be
diagnosed with Alzheimer’s disease, two or more cognitive domains must be affected
(attention, executive functioning, etc.).
Worldwide, over 44 million people are diagnosed with Alzheimer’s disease. Because of
double ageing (people become older and older), the prevalence will increase. The age of
onset is > 60 in most of the cases. In familial (genetic background) cases, it can start below
the age of 60.
Treatment
• In mild to moderate cases: cholinesterase inhibitors
• In moderate to severe cases: NMDA receptor antagonist
Neuropsychological symptoms
It starts with memory impairment. They gradually start to forget more and more things. So
there is a gradual increase in memory impairment, starting with anterograde (after brain
damage → plaques and tangles) loss of episodic memory and later also retrograde amnesia.
The family might notice this first, and the patient later on. Patients also experience
disorientation in place and time, and later, in person. There is a gradual deterioration in
various cognitive domains (language, executive functions, attention, apraxia, deficits in
visual perception). Neuropsychiatric problems, including depression and behavioral
problems, are often experienced by Alzheimer patients. The disease has a heavy impact on
daily life, work and social contacts. The extent of brain damage is related to the extent
of cognitive problems (the more atrophy in the medial temporal lobe → the more/more
severe memory problems, the more global brain atrophy → the more global cognitive
deterioration).
Visuoconstructive apraxia: difficulty with drawing things
Brain reserve and cognitive reserve
There are two hypotheses:
• Brain reserve: the brain reserve hypothesis posits that larger maximal lifetime brain
volume (estimated with head size or intracranial volume) protects against cognitive
decline. This is based on genetics.
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