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Summary Neuropsychological Assessment (book material)
- Instelling
- Tilburg University (UVT)
English summary of book material. Also some notes from lectures are included.
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Summary materials ofNeuropsychological Assessment
Chapter 1 – The Practice of Neuropsychological
Assessment
In de 19th century the idea of controlled observations (linkages between body structures and people’s
common responses to common situations) became generally accepted. In the first half of the 20 th
century, war-damaged brains have led to the development of clinical neuropsychology. There were
large-scale demands for neuropsychology programmes for the damaged brains of soldiers. In WWII
there was the development of many talented neuropsychologists and increasingly sophisticated
examination and treatment techniques. Next to clinical neurosciences, also educational psychologists
and experimental studies of cognitive functions in humans and other animals contributed to the
development of clinical neuropsychology. Some intelligence tests made by some mental
measurement specialists, based on findings by Binet and Spearman, have been included in
neuropsychological test canon. Acceptance of educational testing led to large-scale testing
programmes that has given neuropsychology its important assessment dimension. Animal studies and
clinical reports of brain injured persons generated much of what was known about the alterations
and limitations of specific cognitive functions when one part of the brain is missing or compromised.
Neuroscientists discovered the usefulness of cognitive constructs and psychological techniques when
studying brain-behaviour relationships. In the 21 st century, dynamic imaging techniques further
refined understanding of neural foundations of the brain. In assessments, clinical neuropsychologists
address a variety of questions of both neurological and psychological import. There is a great diversity
of problems and persons for which a great variety of questions could be important. Therefore,
flexibility, curiosity, inventiveness and empathy are important. A rapid evolution of
neuropsychological assessment reflects a growing sensitivity among clinicians generally to the
practical problems of brain impaired patients. There are six different purposes that may prompt a
neuropsychological examination. Different strategies should be integrated to gain the needed
information about the patient. The six purposes are:
1. Diagnosis discriminating between psychiatric and neurological symptoms, identifying a
possible neurological disorder in a non-psychiatric patient, helping to distinguish between
different neurological conditions, and providing behavioural data for localizing the site of a
lesion. The imaging techniques will not identify the nature and strength of the behaviour and
accompanying deficits. also; patterns will differ more or less between people and there are
cases in which the localization of the damage does not correspond with the results from
behavioural tests. Neuropsychological assessment can aid in prodromal or early detection
and prediction of dementing disorders or outcome. Screening also has a place in NP
assessment, when used in a more refined manner to identify persons most likely at risk for
some specified condition or in need of further diagnostic study. Screening tests have been
developed for identifying neurocognitive and neuro-behavioural changes in TBI patients.
2. Patient-care and planning many patients are referred for detailed information about their
cognitive status, behavioural alterations, and personality characteristics, to learn how the
neurological condition has affected their behaviour. The neuropsychologist must therefore
describe the patient as fully as necessary for intelligent understanding and care. Rational
planning usually depends on an understanding of patients’ capabilities and limitations, the
kinds of change they are undergoing, and the impact of these changes. The full report of
description about the patient, should give realistic information of how the patient reacts to
deficits and can best compensate for them, and whether and how retraining could be
profitably undertaken. NP measurements can follow the course of many neurological
, diseases and neuropsychiatric conditions. Therefore, regular examination is necessary in
patients with a degenerative or developing disorder, but also can be used to see whether
adaption after a TBI results in changes. Repeated testing may also be used to measure effects
of surgical procedures, medical treatment or retraining. Brain impaired patients need factual
information about their functioning to understand themselves and to set realistic goals.
Some impairments may diminish a patient’s capacity for empathy, especially where damage
occurs in prefrontal regions. This tends to heighten what mental confusion may already be
present because of the altered patterns of neural activity distrust of their experiences,
particularly their memory and perceptions; feelings of strangeness and confusion
accompanying previously familiar habits, thoughts and sensations. This self-doubt is often
referred to as perplexity, and is usually distinguishable from neurotic self-doubts. Also the
family and closest friends need to understand the patient’s condition in order to respond
appropriately. They need to know the mental changes and what may be their psychosocial
repercussions. Many brain impaired patients no longer fit easily into family life.
3. Treatment planning and remediation much work of neuropsychologists now exist of
treatment or research on treatment. NP assessment is important for determining the most
appropriate treatment for each rehabilitation candidate with brain dysfunction. The
assessment will include both delineation of problem areas and evaluation of the patient’s
strengths and potential for rehabilitation. Repeated assessments are required for adapting
the programme and goals to the changing needs and competencies. Current and centralized
appraisal of patients’ neuropsychological statue enables treatment specialists of different
disciplines to maintain common goals and understanding of the patient and it may clarify the
problems underlying patients’ failures.
4. Treatment evaluation with the increasing use of rehabilitation and retraining services must
come questions regarding their worth. It must be examined for its effectiveness in relation to
costs. NP assessment may help to answer those questions. NP evaluation can best
demonstrate the neuro-behavioural response to surgical interventions or brain stimulation.
Also, testing for drug efficacy and side effects requires NP data.
5. Research NP assessment has been used to study the organization of brain activity and its
translation into behaviour, and to investigate specific brain disorders and behavioural
disabilities. Also techniques require research; their development, standardization and
evaluation. Many tests who are used in NP evaluations were originally developed for the
examination of normal cognitive function and recalibrated for NP use in the course of
research on brain dysfunction. Other assessment techniques were designed specifically for
research on normal brain function. Clinicians are often researchers as well.
6. Forensic neuropsychology nowadays NP assessment widely used in personal injury actions
in which monetary compensation is sought for claims of bodily injury and loss of function.
Most questions referred to a neuropsychologists will either ask for a diagnostic opinion or a
description of the neuropsychological status. Mostly, both questions are important. In
criminal cases, a neuropsychologist may assess a defendant when there is reason to suspect
that brain dysfunction contributed to the misbehaviour or when there is a question about
mental capacity to stand trial. Because NP is being used more in legal areas nowadays, it
seems that a new industry has developed. Therefore, many examination techniques and new
tests have been devised. When dealing with forensic issues, one must take into account that
the claimants in tort actions or defendants in criminal cases may perform below their optimal
level (deliberately or unwittingly). Also, base rates of malingering (simulation) or symptom
exaggeration probably vary with the population under study.
Usually a NP examination serves more than one purpose, even though the examination may initially
be undertaken to answer a single question. Integral to all assessment procedures is an evaluation of
the patient’s needs and circumstances from a psychological perspective that considers quality of life,
emotional status, and potential for social integration. When new information has emerged, the
neuropsychologists will enlarge the scope of inquiry. Where a single examination is required to serve
,several purposes, a great deal of data may be collected about the patient and then applied
selectively.
A frequently raised question about the usefulness of NP assessments concerns its “ecological”
validity: how well does the data resulting from it reflect everyday functioning, or predict future
behaviour or behavioural outcomes? It turns out that there are strong relationships between
neuropsychological findings and ultimate diagnoses, between neuropsychological findings and
imaging data, and between neuropsychological findings and employability. Tests used for
neuropsychological assessment turn out to be predictive.
Historically, neuropsychologists focused on adapting existing assessment tests and techniques for use
with neurological and neuropsychiatric patients while developing new measures to assess the specific
cognitive functions and behavioural dysfunctions identified in NP research. Computerized
assessments were predicted to proliferate, but will never completely be the major avenue. It is
undesirable to have all of the work done by computers. New are the variety of computer-bases
assessment programs now available. Of special interest are computerized virtual reality programs.
Computer-based assessment can permit NP to extend into rural settings in which the psychologist can
evaluate the patient from a distance. The big revolution to come in NP assessment will likely be
multifaceted, dependent in part on the emergence of neuroinformatics and the confluence of three
factors: (1) cognitive ontologies (2) collaborative NP knowledge bases (3) universally available and
standardized assessment methods. Bilder expects that, with computerized assessments, more subtle
task manipulations and trial-by-trial analyses can take place. Those can be more sensitive and specific
to individual differences in neural system function. Nowadays, neuroimaging already has improved a
lot compared to some years ago. The relevance of a particular lesion or abnormality may be more
readily elucidated. Also, tests used for NP assessments are adapted for administration during
functional brain imaging, so that the session results in psychometric data on cognitive brain as well as
brain activation patterns related to those tests. With the new digital and social network
communication possibilities of the 21st century, neuropsychology is facing important challenges for
both greater cross-cultural sensitivity and more language-appropriate tests. Further knowledge is still
needed for tests and testing procedures to be sufficiently organized and standardized that
assessments may be reliably reproducible, practically valid, and reality comprehensible. It is unlikely
that any “one size fits all” battery can be developed or should even be contemplated. It is however
possible to develop a series of relatively short fixed batteries for use with particular disorders and
diseases and specific deficit clusters.
Chapter 2 – Basic Concepts
The neurologist examines the strength, efficiency, reactivity and appropriateness of the patient’s
responses to commands, questions, discrete stimulation of particular neural subsystems, and
challenges to specific muscle groups and motor patterns. Also, he examines structures for
abnormalities. The clinician reviews behaviour patterns, patient’s responses in relatively coarse
gradations and takes note of important responses that might be missing. NP assessment is another
method of examining the brain by studying its behavioural product, but in far more detail than what
is covered in the mental status portion of a neurological exam. Therefore, it uses interviews,
standardized tests and questionnaires. Its frame of reference is brain function (different from
psychological assessment). Some of the earliest instrument to study brain function and remain in use
are electrophysiological such as EEG, ERP and EDA. EEG especially useful in diagnosing seizure
disorders and sleep disturbances and for monitoring depth of anaesthesia. MEG (magnetic form of
EEG) more precise in identifying source of epileptic discharges. MEG and EEG can help in brain
mapping. It is however controversial whether it is a valid clinical approach to be used in the routine
assessment of neurological patients, their spatial resolution is quite poor. EDA reflects autonomic
nervous system functioning and gives a sensitive and very robust measure of emotional responses
and feelings. EDA has been used to demonstrate various nonconscious forms of brain processing.
Often, patients with conditions such as amnesia, apraxia and agnosia cannot remember it, but still
, show a EDA response related to the condition (such as recognition response in patient who is unable
to recognize faces). Other methods that enable visualization of ongoing brain activity are collectively
known as functional brain imaging. Can be used in examining normal brain functioning and the
nature of specific brain disorders. Regional cerebral blood flow (rCBF) reflects the brain’s metabolic
activity indirectly as it changes the magnitude of blood flow in different regions. CT and MRI
techniques reconstruct different densities and constituents of brain structures into clinical useful
pictures of intracranial anatomy. Higher magnet strengths allow even more fine-grained visualisation.
Advanced techniques have evolved from MRI, to give more detailed information. The timing of those
procedures is important for the usefulness, for what kinds of information will be visualized and for
the choice of specific diagnostic tools. PET visualizes brain metabolism directly as glucose
radioisotopes emit decay signals, their quantity indicating the level of brain activation in a given area.
SPECT (single photon emission CT) is similar to PET, but cheaper and has a contrast agent that is
readily available. Procedures like PET and SPECT typically compare data obtained during a task of
interest and data from a resting state. The procedures all have their own limitations; costs,
applicability, accessibility etc. F-FDG PET can be really informative in the early, milder phases of
dementia when diagnostic certainty based on the usual procedures tends to be more equivocal. fMRI
works with the oxygen flow through the brain; more activity requires more oxygen and oxygen is
delivered by blood flow. Important there is the BOLD signal and it is highly localizable, which gives
fMRI a high spatial resolution. fMRI will continue to be involved with neuropsychology as well as
cognitive neuroscience in general. Techniques such as the Wada test and electrical cortical
stimulation mapping have been developed to identify cerebral language and memory dominance in
neurosurgery candidates. Those have reduced cognitive morbidity following surgery, but also
enhanced our knowledge of brain-behaviour relationships. Adverts are that the procedures are
invasive and afford only a limited range of assessable behaviours due to restrictions on patient
response in an operating theatre and short duration of medication effects. The data obtained by
those techniques is often not generalizable.
History:
- 20th century: NP began providing tools and expertise for clinical assessments in psychology,
psychiatry and neurosciences.
- 1930-1940 consultation with a neuropsychologist occurred when a determination was
necessary whether a patient had brain damage or not. Clinicians treated brain damage as if it
was a unitary phenomenon; they did know that disorders resulted from different conditions
and that brain-behaviour correlates appeared with predictable regularity.
- 1950….: brain damage no longer was treated as an unitary phenomenon, but identification of
its presence continued to be a primary goal of assessment. Search for damage focused on
finding tests of different functions that would make the discriminations between psychiatric
and normal subjects.
- Mid-part of 20th century: Luria focused on qualitative analysis and he stressed the value of
analysis of cognitive and behavioural symptoms. He emphasized the importance of breaking
down complex mental and behavioural functions into component parts. He argued that the
complex functional systems are based on jointly working zones of the brain cortex.
- Late 20th century: advances in diagnostic medicine. Focus now on inquiry into patient’s
cognitive strengths and deficits, emotionality and capacity to function in the real world. The
presence was already identified radiologically. The site and extent of a lesion or the diagnosis
of a neuro-behavioural disease are not predictive of the cognitive and behavioural
repercussions of the known condition vary with the nature, extent, location, and duration
of the lesion; with the age, sex, physical condition and psychosocial background and status of
the patient; and with the individual neuroanatomical and physiological differences.
Although ‘brain damage’ may be useful as a general concept that includes a broad range of
behavioural disorders, when dealing with individual patients the concept of brain damage only
becomes meaningful in terms of specific behavioural dysfunctions and their implications regarding
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