Clinical Neuro Notes
Clinical Neuropsychology
Lecture 1
Chapter 1, 2 & 3
1.1 A little history
- 400 BC, Hippocrates hypothesized that all abnormal behaviors and emotions stemmed from the workings
of the brain.
- 1596-1650, Rene Descartes believed that the soul is an independent (immaterial) entity which was located
in the pineal gland.
- 1758-1828, Franz Joseph Gall proposed that there are many mental organs located in the gray matter or
cortex of the brain (phrenology).
1.2 Cell theory:
An important question in brain-behavior debates: where should we locate the soul or mind, how does the
mind affect the body, and which organs play a role in this?
Ancient Greeks: distinguished between three different forms of soul
1) one for survival via food intake (present in plants)
2) one for the activities of an organism in relation to the environment (in animals)
3) one for distinguishing between good and bad (psychikon hegemonikon – guiding principle)
People were the only beings believed to have all three forms of soul. General consensus that the brain played
a big part in locating the souls.
Cell theory of the mind: It was believed that cavities in the brain (the ventricles) – at that time called cells –
were the site of the mind, divided into different structures. 1) the first cell received information from various
senses , 2) the second cell interpreted the image (the input), 3) the image was stored in the third cell
(memoria, or memory). This theory still forms the basis of our idea about cognitive psychology.
1.3 Descartes: an undivided mind:
Descartes philosophized that mind and body are really distinct. According to him, the mind is a thinking,
non-extended thing while the body is an extended, non-thinking thing. Throughout the body, messages about
the outside world were received via the nerves and messages were sent back using memory, as a result the
body could move. Today almost all work is based on materialism.
1.4 Gall and the localization issue
Gall believed that all mental/psychological functions were innate and localized in discrete parts of the brain
(phrenology), and although this idea has been refuted, scientist has come to appreciate some of the work by
Gall. Today the idea that the cortex play a crucial role, and that certain functions do have highly specific
locations is widely accepted. This idea did not go over well with the church back then, as it was entirely
materialistic.
1.5 The clinic-anatomical method
A two-part methodology, strongly promoted by Jean-Martin Charcot, which linked clinical signs with
anatomical (brain) lesions: The first step of this method involved the careful documentation of clinical signs
with longitudinal observation. At the time of death, the second step involved autopsy examination of the
brain. With combined clinical and anatomical data, one was able to suggest concrete links between location
and behavior. One such example is that of Paul Broca, who gave name to the Broca’s area. However, John
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Hughlings Jackson stated that Broca should not confuse he location of a lesion that resulted in a specific loss
of function, with the location of a function (still considered to be a wise lesson).
1.6 Holism
1900 Opposition began to emerge to the localization movement. Holism is an approach to understanding
the human mind and behavior that focuses on looking at things as a whole. It is often contrasted with
reductionism, which instead tries to break things down into their smallest parts
(localization). Holism suggests that people are more than simply the sum of their parts.
1.7 Luria: a global model
The Russian Aleksandr Romanovitsj Luria )1902-1977) were among the first to focus on rehabilitation of
patients with cognitive disorders, and to be guided by Neuropsychological theory and assessment. Luria
sought a balance between holistic and localizationist view.
1.8 An initial impulse: the test battery
Using one or more test battery, psychologist could study and describe cognitive functioning systematically,
which resulted in a specialization by psychologists who worked in neurological departments.
E.g.: Ward Halstead conducted research into the effect of brain injury (in particular frontal lesions) on
intelligence. To this end he developed a variety of tests, and later on (In collaboration with Ralf Reitan, he
converted all these tests into a battery of tests, known as the Halstead-Reitan neuropsychological battery.
1.9 Neuropsychology as an independent discipline
Around 1960 two major developments occurred that resulted in the emergence of neuropsychology as a
separate scientific discipline.
1) The work of Norman Geschwind Encouraged people to work on the basis of Wernicke’s
framework (to look for specific centres and links in order to more accurately chart the functioning of the
brain). An important aspect of this was involved looking for double dissociations.
2) The research of Roger Sperry into the effects of the so-called split-brain surgery. It became
evident that the right side of the brain were better at carrying out certain functions than the left side the
notion of specialized functions of the hemispheres.
1.10 Cognitive neuropsychology
Jerry Fodor (1983) believes that language ability is an innate specific property; we have no
awareness of these language processes and we do not have any control over them. This type of process is
referred to as a module. Fodor initially defined module as "functionally specialized cognitive systems" that
have multiple features but not necessarily all at the same time. A module 1) can only process certain
information (domain specific), 2) is innate, 3) carries out its work regardless of what other processes are
occurring and, 4) is computationally autonomous and has its own neural architecture.
Neuroimaging much greater attention has been devoted to psychological processes in the
brain and to areas of the brain that are active during certain processes, and less attention has been given to
theory development in the field of cognitive processes.
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2.1 Neuropsychology in practice
Neuropsychologists are clinicians with knowledge of neuropsychological symptoms and test
methods. They use their knowledge to carry out diagnosis and treatment of patients with brain disorders.
2.2 Neuropsychological tests
Diagnostic cycle Neuropsychological assessment uses hypothesis testing.
A diagnostic cycle consists of 4 cycles; 1) complaint analysis, 2) problem
analysis, 3) diagnosis and, 4) indication for treatment. For each stage, a
hypothesis is formulated, which is tested. The entire diagnostic cycle is not
always completed.
Referral question and A neuropsychological assessment always starts with a well-defined referral
definition of the problem question.
E.g.: Are the cognitive disorders in line with Korsakoff’s syndrome?
Interview with the patient Important to collect information about current complaints and symptoms and
their progression. This interview consist of both a standard list of questions
and spontaneous follow-up questions. It is also a way of building a working
relationship with the patient.
Interview with the Some referred patients are not always able to provide reliable information
informant about their complaints or they day-to-day functioning. An interview with the
informant is therefore an essential part of the examination.
OBS: does not always provide subjective information, and therefore not a true
representation of the actual functioning of the patient.
Observation Observations are recorded during the interview with the patient, the tests and
even outside the examination room.
Tests and questionaries’ There are many types of tests:
- A fixed test battery consists of a predetermined set of tests that is the same
for every patient, regardless of their complaint or the reason for their referral.
- Specific tests and questionnaires will depend on the referral question and the
psychometric properties.
Interpretation Interpretation involves the integration of all the data discussed above. If the
tests do not show any cognitive disorder, this does not necessarily mean that
no brain injury or disorder is present.
Reporting Reporting on the findings of neuropsychological assessment can be done
verbally and in writing.
Sometimes (according to ethical standards of the country) the content of the
psychological report must be discussed with the patient before the findings
are reported to the referral.
2.3 Reliability and validity
Reliability The accuracy of an instrument reflects the extent to which the result of a
test remain the same when they are collected at a different time or by different
researchers
- The degree of correspondence between the results of different researchers is
called inter-rater reliability.
Validity The applicability of a test whether the test measures what it is supposed to
measure.
- Ecological validity: how accurately a test predicts daily functioning in own
environment.
- Face validity: the extent to which a test initially seems to measure what it is
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supposed to measure
- Content validity: the extent to which a test is representative of the topic that
is to be measured
- Construct validity: the extent to which the results of a test actually reflects
the cognitive function that is being assessed
- Criterion validity: the extent to which a test can predict the performance of a
patient with regard to an actual criterion. Consist of 1) predictive validity
(how accurately a test predicts actual behavior) and 2) concurrent validity (the
difference between a neuropsychological test and another tool that aims to
measure the same criterion)
Confounding The reliability and validity can be undermined by a range of confounding
factors (an element that affects performance on a test bur that does not fall
within the measurement objective of a test)
Underperformance Underperformance (or suboptimal performance) means that a patient’s
performance is impaired compared with what they would be able to achieve if
they were to make a normal effort.
This is dangerous because it can be hard to know when someone is
underperforming due to pain or nervousness, or exaggerating to gain
something. Here it is important to look for inconsistencies within the patient’s
behavior.
There are certain tests to check for this; one is the Amsterdam short-term
memory test.
2.4 Neuropsychological treatment
A treatment plan is made by the neuropsychologist, however, it is also important to take into account the
emotional and behavioral disorders and side-effects from brain injury (grief, frustration, relationship
problems and so on).
2.5 The professional field
Various health care institutions in which neuropsychologist might work
Hospitals The core task of a hospital-based neuropsychologist is to carry out
neuropsychological diagnostics; to identify the cause of cognitive complaints
or to assess the effect of a brain injury that has already been identified.
- treatment is usually short-term and complaint oriented.
- usually collaborate with a number of specialties, including neurology,
rehabilitation, neurosurgery, and internal medicine.
Rehabilitation centers Here the emphasis is typically on treatment instead of diagnosis. A
neuropsychologist working in a rehabilitation center is usually familiar with a
variety of treatment methods. Focus not only on cognitive disorders, but also
on coping issues and complaints such as anxiety and depression that can
occur after an acquired brain injury.
Mental health care - works closely with a team of specialist in different fields.
- The value of having a neuropsychologist in an institution for mental health
care includes the fact that they can explain a patient’s behavior using a
neuropsychiatric model which has cognitive disorders at its center.
Residential homes, Neuropsychologist in this field focus mainly on assessment and support by
nursing homes and family members and other people who are directly involved with the patient.
supported housing
Forensic institutions This is a field that has expanded over the last decades. This is partly due to
the increasing scientific evidence that there is a neurobiological basis for
