Psychological - Lecture 10 - Neuropsychological Assessment (DN)

Experimental Neuropsychology

Clinical Neuropsychology

the “normal” brain

Method: animal & human models (e.g., lesions)

“dysfunction” - particularly CNS dysfunction &

its impact on behaviour & quality of life

Assessment

Rehabilitation

8:00

professional within the field of psychology

special expertise in applied science of the brain-behaviour relationships

9:50

they use this knowledge to assess, diagnose, treat &/or rehabilitate patients with

neurological, medical, neurodevelopmental & psychiatric conditions

as well as other cognitive & learning disorders

10:50

Treatment engages some technique applied to a client

Rehabilitation applies a dynamic interaction between patient, clinician, family & community resources to achieve maximum possible recovery

(we know that most of CNS will not fully recover) but need to work to maximum possible recovery to improve client’s daily life

Type of Problem

Populations

Settings

Services

15:35

characterisation of impairment

differential diagnosis e.g., between dementia & other conditions

measurement of change

preliminary baseline measurement e.g., Parkinsons disease to track change

applicable to every dysfunction that can be detected early (huntingtons, MS)

prediction of functional outcomes

e.g., can this person continue to work / drive safely etc)

planning rehabilitation

rehabilitation

16:05

Neurological

brain injury

Psychiatric

depression, OCD, schizophrenia

General medical & surgical

vascular conditions impacting brain

Professional

sports (brain trauma, post concussional syndrome), occupational (exposed to neurotoxic agents)

Children (learning disabilities, developmental disorders)

22:45

Hospitals

Clinics

Forensic

Private Practise

25:35

Neuropsychological Assessment

Cognitive remediation & intervention

Neuropsychological rehabilitation

Psychological therapies (for brain dysfunction)

e.g., personality problems resulting from brain injury may require specific therapies

Counselling to Public Agencies, Private Companies, Educational Centres

25:50

40%

Old Views - relevance to current views

locate the lesion -

other techniques are better equipped for this (e.g., brain imaging)

current priority is to characterise cognitive status

determine organicity -

do not distinguish between organic & non-organic (psychological)

current view is that it is always organic & always psychological

provide a reasoned account of cognitive strengths & weaknesses

neurological or psychiatric diagnosis -

this is for a neurologist or psychiatrist

role is to work out how neuropsych system works and what is not working well

determine functional (everyday) impact

provide a neuropsychological diagnosis

27:25

Why is this assessment necessary

Fixed Battery, Pattern Analysis

Flexible Approach, Hypothesis Testing

assess only particular parts of system that you think are causing the problem

Fixed Battery

Quantitave

gives you numbers - interpreted relative to norms

Outcome Focussed

scores/performance

Matrix Vision

Comprehensive

Flexible Approach

Mixed Quantitative/Qualitative

Process Focussed

why did the client achieve this outcome, what compensatory processes, what could he have done differently

Modular Vision

assumes certain systems of brain are specific to certain functions

isolated on other systems of the brain

so only focus on module which is dysfunctional

Hypothesis-driven

Systematic

always done the same way

Comprehensive

addresses every possible cognitive determinant

Objective Interpretation

scores can be trasformed into deficits or strengths

Easy to train

Easy to replicate

37:15

Patient-tailored

individuality of each case

Focus on relevant domains

not whole system

Process (WHY) emphasis rather than outcome (WHAT)

Time efficient

38:00

Disadvantages of

Fixed Battery

time consuming

could take 6-10 hours just for administration of instruments

relies on availability of quality norms

this is because reliance is on the outcomes

provides reference framework for interpretation of scores

Flexible Approach

Susceptible to bias

hypothesis may be wrong

clinician may be misled by certain factors

could mistakenly exclude vital points

e.g., referall from lawyer - could bias you by adding relevance to some symptoms

Relies on training/experience

38:35

It depends on the referral question

42:05

diagnosis - 70%

rehabilitation/treatment planning - 48.3%

forensic - 31.8%

educational planning - 29.6%

capacity to work assessment - 27.9%

establish baseline function for future testing - 24.3%

assess capacity for independent living - 19.7%

pre- and post-medical intervention - 9.6%

localisation of lesion 2.7%

source Rabin et. al., (2005)

42:30

in the diagnosis of certain language disorders

it was established that using a relatively small number of tests language disorders

e.g., aphasia could be accurately diagnosed

Fixed

as don’t want to miss anything

also has other implications

need to measure against population norms

findings also need to be replicable as other professionals will likely be assessing

Flexible

very specific referral question

posterior parts of brain are more modular

perceptual, language, motor is probably ok to do flexible

wheras general cognitive ability or memory etc would need Fixed

Fixed

Replicability

Many professionals involved

Court - challenged, needs to be backed up by systematic assessment

Fixed

in sports concussion

brain moves a lot - damage may be away from injury site

best to go broad, so as not to miss anything

51:50

Flexible

already have a diagnosis

know what typically occurs in MS

53:20

Most people use a combination of approaches

54: 30

An intial "fixed" set of attempts to cover all relevant domains

(i.e., cover most of cognitive system)

to develop broad quantitative profile

Develop hypothesis

Select specific instruments to examine hypothesis

Interpretation or Reiteration

54:45

Phase 1 - Interview

Phase 2 - Selection of Instruments

Phase 3 - Administration of Instruments

Phase 4 - Interpretation of the whole assessment

56:25

Interview

Clarify the Referral Question (this should be done before the interview)

Medical History

via patient, relatives

Developmental Milestones

School/Occupational History

Psychosocial History

Symptoms: evolution & coping

56:35

Selection of Instruments

based on the:

referral question

selected approach

information collected at the interview (phase 1)

Administration of Instruments

Neuropsychological Tests

Personality/Mood Scales

Behavioural Trials

Life-log

Interpretation of the whole assessment

History analysis

Observations

Test scores

Qualitative observations

Estimated impact

Feedback is ongoing, not just at the end

Medical/psychiatric history

Neuropsychological test data

Referral source

Psychsocial history

Mood & affect measures

Developmental history

Current social supports

Objective personality tests

Mental status exam

Significant other interview

Environmental demand charcteristics

Behavioural assessments

School records

Functional Assessments

Work records

Projective personality tests

source: Rabin et al., (2005)

58: 50

Important to understand how the patient was before the dysfunction

e.g., in order to differentiate lesion related injury from pre-morbid condition

Patient

Relative (significant other)

Both together

1:01:05

create rapport - trust, empathy

will get more accurate information from them

comprehensive history

developmental

medical

vocational

social

helps to understand how the brain works in different situations

Allow patient directed (idiosyncratic) description of symptoms

current, evolution, coping

Attention to Potential Gains

e.g., financial, legal, emotional (attention)

1:01:50

Double check history, symptoms

Enquire about more interpersonal aspects

e.g., husband, wife, child - how is the patient engaging socially

affect, empathy, communication etc

Enquire about blind spots

1:04:02

Observe interactions

how the relative treats patient (e.g., like a child, or harshly)

Gently confront inconsistencies

Request additional information

Outline the assessment plan

1:04:50

Always:

Adapt instrument to

referral question (relevant, comprehensive)

patient status (floor, ceiling)

expected prognosis (repeated testing requires test that allow for this)

Norms (e.g., Cultural - American vs. Russian norms - fast vs. slow accurate completion)

Reliability

Construct Validity

Be aware of the test limitations - there is no pure Neuropsychological test

Depending on the referral question:

Sensitivity vs. Specificity

ecological validity: Veridicality vs. Verisimiltude

Forensic Cases:

Attention to base rates, predictive value

Select replicable tests

Include malingering tests

1:07:05

Need test that will distinguish between the two

Weigh up sensitivity & specificity

1:11:35

need to consider ecological value of test

need to predict how the surgeon will perform the type of tasks normally involved in this position

1:12:25

Prioritise tests assessing memory function, attention, and cognitive performance to objectively evaluate the client’s complaints despite the lack of neuroimaging or biomarker evidence.

Focus on tests measuring cognitive functioning, work-related abilities, and functional impact to provide evidence for workplace accommodations for the recently diagnosed MS client.

General batteries

Domain-specific batteries

Disorder-specific batteries

Setting-specific batteries

1:13:05

WAIS

can be interpreted from a Neuropsych perspective

Halstead-Reitan

been used extensively as fixed battery

CANTAB

Luria-Nebraska

Category

Tactual Performance

Rhythm

Speech sounds perception

Finger-tapping

Time sense

Other tests included are - Trail Making Test, Strength of Grip Test, Miles ABC Test of Ocular Dominance, WAIS, MMPI, Aphasia screening

p.560 Text - Table 15-7

a fixed battery

LNNB takes about 1/3 of the time of Halstead-Reitan

contains clinical scales which assess cognitive process & functions

Analysis of scores leads to judgement on whether impairment exists

if so which part of the brain is affected

p.559

Cambridge Neuropsychological Test Automated Battery

computer-based cognitive assessment battery

administered using a touch screen computer

consists of 22 tests

examines various areas of cognitive function

general memory and learning,

working memory and executive function

visual memory

attention and reaction time (RT)

semantic/verbal memory

decision making and response control

Warning: this slide is taken from WIKI (couldn't find in text)

McQuarrie (Motor) Boston Diagnostic Aphasia Examination

Wechsler Memory Scale

Delis-Kaplan Executive Function Systems

the Neurosensory Centre Comprehensive Examination of Aphasia (NCCEA)

focus: communication deficit

the Montreal Neurological Institute Battery

helps locate specific kinds of lesions

the Southern California Sensory Integration Tests

assess sensory-integrative & motor functioning in children 4-9yrs

the Severe Impairment Battery (SIB)

used with severley impaired who may perform near the floor of other tests

the Cognitive Behavioural Driver's Inventory

determines whether brain damaged individuals are capable of driving a car

p.561 - text

MATRICS Consensus Cognitive Battery

Schizophrenia

CAPSIT Protocol

Parkinsons Disease

Sports Concussion Battery

Military

0-3 yrs milestones

IQ or Academic Achievement Test

what are abilites required for different courses etc

Information input & output (Perceptual/Motor)

Language

Attention

Memory

Executive Functions

Social Cognition

empathy, understnading humour etc.

Personality

Everyfay functioning

Effort/Malingering

1:17:25

Visual Perception

Visual Discrimination Test

Judgement of Line Orientation Test

Visual Integration

Hooper Visual Organisation Test

Visual Construction

Rey Complex Figure-Copy

Clock Drawing

Bender Visual-Motor Gestalt Test

Motor Speed

Finger Tapping

Motor Dexterity

Grooved Pegboard

Tactual Performance Test

1:19:25

Perception

distinguish between sound, phonemic. lexical levels

Comprehension

rule following test

Production

free speech analysis

Repetition

Reading/Writing

Syntax

verbs, planning/sequencing

some times related to executive function

Semantics

access, concepts

also relatd to executive function

1:19:50

Episodic Memory

Verbal learning & memory: Word lists (15-16 words)

Learning Slope/Encoding (5 trials)

hort-term after interference memory (3 mins)

Long-term memory (20-30 mins)

Recognition (Recollection/Familiarity)

Verbal forgetting: Selective Reminding Test

5-trial word list

subsequent presentations (2,3,4,5) dont repeat previously learned words

Visual Memory:

Rey Complex (but watch perceptual/motor)

Continuous Visual Memory Test

Semantic memory

Verbal Fluency by Category

Logical memory

Gist from passages, stories

Procedural memory (HM case study)

Repeated drawing accuracy

Meta-memory

120:55

Episodic Memory

(which is a form of declarative memory)

1:23:20

Episodic

1:23:35

using word lists

Learning Phase: Learning Slope/Encoding (5 trials)

Short-term after interference memory (3 mins)

Long-term memory (20-30 mins)

Recognition (Recollection/Familiarity)

1:23:45

Learning

Encoding

Recovering

Forgetting (Degradation of information)

125:45

Episodic & Semantic

Rey Complex Test

Abstract picture - cannot use things that can be associated with words or semantics, so they are actually remembering what they see

asked to copy it

after 3 mins > free recall

after 30mins > delayed free recall

4.

12-14 elements in immediate recall

10-12 elements in delayed recall

1:28:20

by comparing Immediate, Delayed & Recognition Phase scores

e.g., low scores on immediate & delayed, but high score on recognition may suggest the problem is with memory retrieval, not encoding or storage

executive processes

e.g., gradual decline from immediate, to delayed, to recognition (information is vanishing with time, forgetting)

could suggest degradation of temporal lobe

130:25

complex to assess

Energising, Focus, Orientation

Reaction time based tasks

Visual/Auditory discrimination

Matching familiar figures

Seashore Rhythm Test

Attentional Span

Digits

then more complex which also involve executive function/control

Sustained Attention

Continous Performance Test (CPT)

Cancellation tests

Selective Attention

Stroop

Divided Attention - alternate

PASAT

1:31:30

Attention

1:34:15

Inferring

Similarities

Proverb
20 questions

Working Memory

Letter Number Sequencing

N-back

Self-Ordered Pointing

Response Inhibition

Stroop

Hayling Sentence Completion

Stop-Signal

Planning

Tower of Hanoi

Mazes, Picture Arrangement

Shifting

Wisconsin Card Sorting Test

Trail Making Test

Category Test

Decision-making

Iowa Gambling Task

Cambridge Gamble Task

1:34:40

Executive function

specifically 'Inferring'

Executive function

specifically 'Working Memory'

Executive function

specifically 'Response Inhibition'

Executive function

specifically 'Planning'

Executive Function

specifically 'Shifting'

Executive Function

specifically Decision Making

no single executive function test is a pure measure of any single function

i.e., is measuring a tiny portion od each of the executive domains at the same time

e.g., TMT is measuring 'shifting' or flexibility

but in order to do this you must first 'inhibit' immediate tendency to go from 1 to 2 or A to B

e.g., Nback is measuring 'working memory' or updating

but will involve 'shifting'

e.g., Tower of Hanoi is measuring 'planning'

but engages 'working memory' (to project number of movements), 'inhibition' (tendency to just move), 'flexibility'

1:37:40

Most info comes from triangle of face (eyes, nose, mouth)

Emotion recognition

Eyes test

Empathy

Theory of mind

Faux Pas

Moral Dilemmas

low conflict vs. high conflict (analyse what the style of people)

some people have a deontological approach

some have a utilitarian, concrete thinking approach (stole motor bike coz keys were there)

Affective Prosody Perception

Humour Processing

General personality tests

MMPI, MCMI

Projective tests

TAT

helps access inner experience of brain injured patients

Specific personality change scales for brain dysfunction

Iowa Scales of Personality Change

BRIEF

FrSBe: Frontal Systems Behaviour Scale (1:45:00)

Apathy

Disinhibition

Executive Dysfunction

Rivermead Behavioural Memory Test

Test of Everyday Attention

Behavioural Assessment of the Dysexecutive System

Poker cards N-back

Key Search (box - draw best strategy to find the keys)

Zoo Map (plan a visit to the zoo, following social rules)

Multitasking

Clinic-based - Hotel Task (like a real-life job, concierge in hotel)

Outside clinic - Multiple Errands Test

Neuropsychology so often tries to predict daily life using tests that are very structured and artificial

Ecological approach addresses this issue by utilising real life situations

optimise patient/client performance

minimise performance anxiety

hide tools e.g., timer

maintain rapport, alertness

provide clear guidelines

order is important (balance difficult items, with timing etc)

stick to manual instructions

If Quantitative - must have good norms

Best way is to Integrate all sources of information

Articulate response to the referral question

Communicate results of the assessment clearly to the patient (verbal, report)