PSY71 - Neuropsychological Assessment

PSY71 - Neuropsychological Assessment - 8832332885 18:82...

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Unformatted text preview: 8832332885 18:82 51—3?2Ed8?8 F'ihGE 81318 1 W25 The Practice of Neuropsychologlea. Assessment Imaging is not enough. MerrimiErMishkin. 7%? demands for neuropsycholog Programs. Now many psychologists, psychiatrists. and counselv ors ask for neuropsychological assistance in identifying those candidates ['or their services who may have underlying neurological. dison ders. Neurologists and neurosurgeons are in- creasing their requests For behavioral. evalua— tions to aid in diagnosis and to document the course of brain disorders or the effects of treat- ment. A :l'ruitiill interaction is taking Place be- tween neuropsychology end gerontology that enhances the knowledge and clinical applica— tions of each discipline. Child. neurcrpsycliiology has been developing hand. in hand with ad.— vances in the study or mental retardation. learning disabilities, and children’s behavior problems1 (Best. 1935,- Ivan, 1934; Njiolcik- tjien. 1938; Obtain and Hync], 198621.13; Rourke, Baldter. Fisk. and Strang, 1983: E. M. Taylor, 1959; B. C. Wilson, 1936). When this book first appeared, much of the empties-is in clinical neuropsychology was on assessing behavioral change. in part this oc— curred because so much of the demand on. neuropsychology had been fer assistance with diagnostic problems. Moreover, many patients seen by neuropsychologists are so limited in. their capacity to hen.th from training Pro- grams and counseling that these kinds oi treat- Clinical neuropsychology an applied science concerned with the behavioral expressicn 0i. brain dysliinction. Its rapid evolution. in recent years reflects a growing sensitivity among cli- . nicians to the practical problems of identifica— ,. Lion, assessment, care, and treatment of brain damaged patients. When doing assessments, clinical. necropsy- choiegists typically deal with. a variety of ques- tions. a wide range of behaviors. and the very disparate capacities of their patients. This di- versityr of problems and persons presents an unending challenge to the examiner who wants to satisfy all. the purposes for which. the exam- ination was undertaken. and still evaluate the patients at levels suited to their capacities and limitations. Moreover, in this complex and broad—ranging field, few facts or principles can be taken for granted, there are few techniques that cannot benefit from modifications. and few rules oilproeecli,1re that. will not be bent or bro- ken as knowledge and experience accumulate. The practice of necropsyehclogy calls for flex; ihility. cudosity. and inveniiveness even in the most routine work. But even the reutine work OF the neuropsychologist holds the promise of new insights into the workings oithe brain and the excitement of discovery. The need for screening and diagnosis of ‘ brain injured and behmfioranv (“Shirl—Jet] sen“ 'The assessment ofchildren and the consideration oi: brain . , , , _ _ disorders presenting prior to maturing have their own con- mgmen dlmng Wart-lime and for Hm” whalnll’ ceptual framework. methods. and date. which are runi-sirie tation FIFterwards created the. first large-scale the scope oi'i‘his book. 9832332895 18:82 Ell??2En-4EI?E F’r'l'uGE @2319 3 THEORY AND PRACTICE OF NEUROPSYCHDLOGICAL ASSESSMENT mcnt are not practical options for their care. Then, too, as one of the clinical sciences, neu— ropsychology has been evolving naturally. for assessment tends to play a predominant role While these sciences are relatively young. Treatment techniques develop as diagnostic categories and etiological relationships are de- fined and clarified. Any of four different Purposes may prompt a neitrepwchological examination: diagnosis; patient care—including questions about man- agement and. planning; treatment—for devel- oping treatment programs and for evaluating their efficacy,- and. research. Each purpose calls for some differences in assessment strategies. 1. Diagnosis. Neuropsychclogical assessment can be usel'ul in discriminating between. psy- chiatric and neurological symptoms, in identi- Fying a possible neurological disorder in. a non- psychiatrlc patient, in helping to distinguish between different neurological conditions, and in providing behavioral. data for localizing the site—or at least the hemisphere sided—oi a le— sion. However, accurate diagnosis, including localization of a lesion. is most often achieved by means olhthe nourologist’s examination and laboratory tools. Neuropsychology‘s diagnostic role, which predominated in. its early years, has diminished as its centributicns to patient care and treatment and to understanding behavioral phenomena and brain Function have grown. More than any other advanca in techniques For the diagnosis and. localization of pathologi- cal conditions of the brain, computerized in- triogrephy (CT semi)‘ and the more recently developed mgnetic resonance imging (Ml-ll)“ have reduced. the instances in which necropsy- cliological assessment, along With most other older diagnostic procedures, may malce a delin— itive contribution to the diagnostic process 'Sometlmes called CAT scan. for computerized axial to- mogrephi, or CTT soon. for computerized transmittal to. materially: a ncuroradlologlcnl technique that provides im- ages of the dii'llerent densities of internal. structures, thereby permitting visualization of lnlirncraninl anatomy. inlso know as mmer magnetic imging {NMI}. "Nu- clear" was dropped from the name became of the aai- hility that lay persons would be inapproprlately fear ul cl‘ =1 teehm cc. named with a word many people associate with potentialdanger. ‘ “ (Bigler. Yen, and Turltheimer, 1989; Jernigan, 1990; Pylcett, 1932; Theodore, 1988a.b). Still, there are Conditions in which even the most sensitive laboratory studies may not he diag— nostically enlightening, such as toxic encepha- lopathies, Alzheimer’s disease and related de- menting processes (H. Damasio and Damasio, 1989; Filley and Cullun'l, 1993; .Kertesz, Polk, and Carr. 1990), and mild head trauma (Eisen- herg and Levin. 1989:. Groswasser et al., 1987;. B. D. Jordan and Zimmerman, 1.990; R. B. Snow et al., 1986}. In these conditions the neu- ropsychological Findings can be diagnostically crucial. Thus neuropsychological tcchniqpes will most likely continue to he an essential. part of the neurodiagnostic armamentarium. Although. limited in its applications as a pri- mary diagnostic tool, neuropsychological as— sessment can aid in predictioanhEther it be the outcome of a diagnosed condition (Benton, 1985) or the likelihood that neuropathological condition will. be manifested (Bell, 1985}. As one example of its many purposes, the neuro- psycltological examination ol“ post coma head trauma patients in the early stages following their retum to consciousness is prognostic of their eventual. outcome. These. early stage eat- aminations, given at a time when the patient’s neurcpsychologieal presentation may be changing rapidly, sewe to indicate the seveiity of the injury {Newcomhe .1985}. 111 persons at risk for Huntington's disease. the earliest evi— dence of illness may show up as subtle altera- tions in nourepsychoiogical status hesi- eh- serverl hy refined assessment techniques (Brandt, Fitrmiss. T...:.=u'|.1s, et al., 1984; “I”. Din- mond et al., 1992}. Screening is another aspect ell diagnosis. Un- til quite recently, screening was a rather crudely conceived affair, typically dedicated to identifying "brain damaged” patients from among a diagnostically mired population. such as might be found in long-term psychiatric care facilities. Ll'tlllii attention was Paid to either base rate issues 01' the prevalence of conditions in which psychiatric and organic contributions were mixed and interactive (cg, see papers by C. G. Watson and his colleagues, 1968, 1971, 1978. Mapou. 1.988. and A. Smith, 1933, p. 467, discuss this issue). Yet screening has a place in necropsychological assessment when used in a 8832332885 18:82 :HDLDGICAL ASSESSMENT [‘urkheimer, 1989; Jfil‘i'ligflnw 2; Theodore, 1988a,b). Still, ms in which even the roost -y studies may not he diag— ning, such as toxic encepha— ier's disease and. related de- : (H, Damasio and Damasio, Jullurn, 1993: Kettesz, Polk, nd mild head trauma (Eisen- 389; Croswasscr et al., 1987; 1 Zimmerman, 1990: h. B. In these conditions the neon idings can he diagnostically impsychological techniques some to be an essential part cstic armamentariurn. d in its applications as a pri- tool, neuropsychological as- in predictiona—whether it be liagncsed condition (Benton, that a neuropathological liiianifosted {13011. 1955). As i" any purposes, the neuro— , tit-ion 0le post coma head early stages following busnoss is prognostic of is. These early stage ex- time when. the patient's esentation may he to indicate the scvcrity I 1985)- in. persons at “ case. the earliest evir ow up as subtle altera- mpgical status best ob- ‘ asbcssu'um‘l: techniques at al.. 1934-, T. Dia- ect of diagnosis. Un- iting was a rather ically dedicated to ed" patients From. population. such psychiatric care as paid to either ., see papers by its, 1968, 1971, a, 1.983. p. 46?. g has a place in when used in a Ell—322E-48'H3 PhGE 83318 THE PRACTICE OF NEURDPSYCHOLOGICAL ASSESSMENT ‘9 more refined manner to identity persons most likely at risk For some specified condition or in need of Further diagnostic study (Kane, Gold— stein et al.. 1939). Examples of such specialized uses include identifying which elderly patients presenting with memory complaints need a full. dementia workup (Bentom 1985} or which youngsters beginning school. are likely to havc reading problems (Rourke and. Gates. 1981; Si- van and Carmen, 1986). 2. Patient care and planning. Whether or not diagnosis is an issue, manypatients are referred for detailed information about their cognitive status and Personality characteristics—(idem with questions about their adjustment to their disabilities—so that they and the people re- sponsible for their well-being may lmow how the neurological. condition has affected their behavior. At the very least the neuropsycholo- gist has a responsibility to describe the palflent as hilly as necessary for intelligent understand- ing and care. Descriptive evaluations may he employed in many ways in the care and treatment of brain injured patients. Precise descriptive informa~ tion about cognitive and emotional status is ess sential. for careful. management of many neu- rological disorders. Rational planning naually depends on an. understanding of patients' ca- pabilities and limitations, the kinds of psycho logical changes they are undergoing, and. the impact of these changes on their experiences of themselves and on their hchcvior. A 55-min” told right-llmull'rl urmrlgr'mt'rlt c‘spc‘rt with a bachelor's dcgrcc in economics was hospitalized with a stroke involving the left ironic-parietal cortex those months after taking over as chief executive of- EL‘ET ot a [murdering firm. He made his repu- tation as an eiTectivc troubleshootcr who had cle- Voted must oi“ his waking hours to his work. In this new position. his first as CEO. his responsibilities Ciillfiil {01' abilities to analyze and integrate large amounts ofinl'ormation, including complex financial and sales and manu‘lacturing reports; cre- am": thinking; good jl'idgment; and rebuilding the employees faltering morale. Although acutely he had displayed right—sided weakness and diminished Emotion involving both his arm and leg. motor and. iiETISi-u‘r hmctiuns rapidly returned to near normal [Wait and he was discharged From the hospital. atth- 10 days. Within 5 months he was walking 3'1": miles daily. using his right hand for an estimated 75% of activities, and he Felt tit, and ready to return to work. In questioning the wisdom of this decision. his neu- rologist referred him for a neuropsyohologjcal ex— amination. This bright man achieved tcst scores in the high average to superior ability ranges yet his perfor- mance was punctuated by lapses of judgment leg, when asked what he would do it‘ he was the first to see smoke and Fire at the movies he said, "Ii-"you‘re the first—it it‘s not. a dangerous fire try to put it out by ymlrself. However. if it's a large tin: beyond your control you should immediately alert the audience by yelling and. screaming t‘lILEl capturing their attenn don." when directed to write what was wrong with a pichire portraying two persons sitting comfortahly nut in the rain. he listed seven diFferent answers, such. SIS. "Right hand side of rain drops moves [std to right on right side oi" pict. fatal," but completely overlooked the central problem). Impaired self- monitoring appeared .in his very that performance of a task requiring the Subject to work quickly while keeping track of what has already been done (Fig— ural Fluency Test), as he worked Faster than most persons but left a trail of errors; in his assigning nun-I.- bcrs to symbols From memory (Symbol Digit M0:- ululiries Test) without noting that he gave the same number to two different symbols that are onlyinches apart; and in allowing two small errors to remain on a page of arithmetic calculations done without a. time limit. Not surprisingly, he had word-finding dilj'l'iculn ties, which shmvcd up :in his need for phonetic cursing to Ttii‘i'lEVE! sis words on the Boston Nearing Tr's'i‘ while not recalling Iwo even with tanning: and appeared also in his speech as, for example, hc stated that a dog ELTIC‘l a-lion were alike in being “both mem- hers of the animal Factory. I mean. animal. life.“ On. seli'nreport oi" his emotional status (Beck Depression. Mounted}: Symptom Check List-Qfl-H) he portrayed himself as having no qualms, authoring no emolional or psychiatric symptoms. In interview the patient insisted he was ready to return to a job that he relished. He reported that. as his work has been his life, he had no "extracurricu- lar" interests or activities. He dcnicd that Fatigue was a problem or that his temperament had changed, insisting he was Fully capable of resuming all o:|:' his managerial duties. It was concluded that the relatiyelysuhtle deficits could be serious impediments for this pa- 8832332885 18:82 El??2E~48?B PhGE 10 THEORY AND PRACTICE OF NEURDPSYCHOLOGICN. ASSESSMENT tlcnt at his occupational level. Momover his lac}: of appreciation of these deficits and the great extent to which his life—and sense of dignity and selfuworth— were bound up in his worlc suggested that he would have difficulty in understanding and accepting his condition. and adapting to it in a constmctive man- ner. His potential for serious depression seemed high. The patient and his wife were seen together shortly thereafter for a report of the examination. findings with recommendations and to evaluate his emotional situation in the light of both his wife's re- ports and her capacity to understand and support. him. With his wife present, he could no longer deny fatigue since it was indeed a problem that under- mined hoth his efficiency and his good nature. as evident in her examples of how much better his et- Ficicncy and disposition were in the morning than later in the day. She welcomed learning about his fatigue as his untypical irritability and cognitive lapses had puzzled her, and it was only now that she recognized these tended to be flitcrnnon and eve- ning. not morning. occurrences. With his neurol— ogists perrnission1-he now had definite plans to re- turn in work—liar half-days only, and with an "asaistant" who would review all of." his actions and decisions. help he had to accept alter some of his failures in self-monitoring had been reviewed with him, along with the enmurag‘ng information regard- ing his many well—preserved abilities. (Judgmental were not pointed, out: that did not seem nec- essary as his wile was an intelligent. soundly practi- cal, and strong-minded person who seemed very ca- pablc of dealing with judgment problems at home, and his judgments at work would he under C‘tn'll'in- uous scrutiny. He could comprehend the concrete cadence of written selfnmonitoring errors. but the more complex and abstract issues inspired in eval- uatingjtldgments are more difficult to communicate to persons whose abilities to hsuiclle complex abstrac- tions are impaired. Moreover, hearing that his stroke had. rendered him careless and. susceptible to Fatigue was enough had news: to have given more discour- aging inform ati on than was practically needed at this time would. have been cruel, and probably counter- productive.) . An interesting solution was Worked out for the problem ol'how to get this self-acknowledged work- aholic to aoecpt a Fourwhour work day: it he went to work in the morning. his wife was sure he would soon begin Stretching his time limit to five and Six or more hours. He therefore agreed to go to work after his morning walk or a golF game and. a midday rest period so that. uniting at the office after J. PM. he was much much less likely to exceed. his halt-day work limit. Ten months after the stroke the patient reported that. he was working about 60 hours per week and. had been told he "was doing excellent work." He described a mild naming problem and other minor confusions? He also acknowledged some Feelings of depression in the evening and a sleep disturbance for which his neurologist began medication. Neuropsychological data are liltcly to pro- vide the most sensitive indiccs of the extent to which medications enhance or compmmise a patient’s mental efficientsy. In many cases the necropsychclogical Examination can answer questions concerning patients capacity for self- oare, reliability in following a therapeutic reg- imen, ability not merely to drive a car but to handle traffic emergencies, or appreciation of money and of their financial situation. When all the data c? a comprehensive neuropsycho- logical examin.atlon-—-the patient’s history, background, and present situation; the quali- taiive observations; and the quantitative scores—arc taken together, the examiner Should have a realistic appreciation of how the patient reacts to deficits and can best compen- sate for them, and whether and how retraining could be profitably undertaken. The relative sensi vat-y ancl precision ul‘ueun topsychological measurements malcc them well suited for following the course of many nou- rological diseases. Data from successive oeu- ropsyobological examinations repeated. at reg« ular intervals can provide reliable indications of whether. the underlying neurological candition is changing, and if so. how rapidly and in what ways. Parente and Anderson (1984.) used re- peated testing to ascertain whether brain in jured candidates for rehabilitation could learn well enough to warrant cognitive retraining. Frcides (1985) recommends repeated testing to evaluate performance inconsistencies in pa- tients with. attentional deficits. Deterioration on repeated testing can identify a demcnting process early in its course (I. ('1. Morris, 8832332885 18:82 LOGICAL ASSESSMENT Lime limit to five and six or I agreed to go to work after f game and a. midday rest 7 the office after 1 PM. he 21y to exceed his half-day trolce‘the patient reported it 60 hours per week and .oing excellent work." He problem and other minor rwledged some feelings of g and a sleep disturbance began medication. data are likely to pro- indices of the extent to IBIIBB or compromise a ncy. In many cases the amination can answer aticnts’ capacity for self- wing a therapeutic reg— ly to drive a car but to cies, or appreciation of iancial situation. When. rehensive neuropsychm the patient's history. mt situation; the quali- ancl the quantitative gather, the examiner appreciation of how the :s and can best compen- ther and how retraining lertalten. Ity and precision. of neu- rernents make them well to course of many neu- :a from successive neu- aations repeated at reg- i‘le reliable indications of -‘ neurological. condition rapidly and in. what 01" (1984) used re- "Wliether brain in- -l 23X .Jfi ‘4 (gli'fimfilfi‘m‘ ‘ El??2E~48T8 PrfiGE 85.318 THE PRACTICE OF NEUROPSYCHOLOGICAL ASSESSMENT 11 McKeel, Storandt, et al., lQQl). Repeated test- ing may also be used to measure the effects of surgical procedures, medical treatment, or re- training“. A single, 27-year—old highly slcillerl logger with no history of psychiatric disturb ance underwent surgical removal of a. right anlIO-tcmpfllffil subdural hema- toma resulting from a car accident. Twenty months later his mother brought him, protesting but docile, to the hospital. This alert, oriented, but poorly groomed man complained. of voices that came from his teeth, explaining that he received radio waves and could “communicate to their source." He was emotionally uncxpressive with sparse speech and frequent 20—80-second response latencies that oe- oasionally disrupted his train of thought. He denied depression and sleeping or eating disturbances. He also denied delusions or hallucinations, but during an interview pointed out lchabod Crane's headless horseman while looking at some buildings across the hospital lawn. As he became comfortable. he talked. more freely and revealed that he was continually troubled hy delusional ideation. His mother com- plained that he was almost completely reclusive, without initiative, and indifferent to his surround- ings. He had some concern about being watched. and once she had heard. him muttering, "I would like my mind baclt." Most of his neuropsychologieal test scores below those he had obtained when examined 6% months after the injury. His only above average scores were on two tests of well-learned verbal. material: background information and reading vocatmlary. He received scores in the low average to borderline definitive ranges on oral m'ithmciic, viscometer tracking, and all Visual reasoning and visuoconstruolive—including drawing—tests. Al- though his verbal learning curve was considerably below near-age. immediate verbal span and verbal re- tention were all within the average range. Immedi- ate recall of designs was defection. Shortly after he was hospitalised and had. com- plcted the 20-month examination, he was put on tri- l'luoperazirte (Stelazine), 15 mg h.s., continuing this treatment For a month while remaining undcr hos- pitai observation. He was then reexamined. The patient was still. poorly groomed, alert, and oriented. His reaction times were well within nar- nml limits. Speech and thinking were unremarkable. While not expressing strong emotions. he smiled. complained. and displayed irritation appropriately. He reported what hallucinating had been lilte and related the content of some of his hallucinations. He talked about arranging for a physical activities pro- gram when he returned home but felt he was not yet ready to worlC. His test scores 21 months after the injury were mostly in the high. outrage to .mperior ranges. Much of his gain came from faster response times that en- abled him to get full credit rather than partial or no credit on timed items he had completed perfectly but slowly the previous month. Although puzzle con- structions (hoth geometric designs and objects) were performed at a high onerrrge level, his drawing con- tinued to be Dillon: average quality (but better than at 20 months). All verbal memory tests were per- formed at. average to high average levels; the visual memory test was performed without error. gaining him a superior rating. He did simple visuomotor traclcing taslts without error and at an average rate ofspeed; his score on a complex visuomotor tracking task was at the 90th percentile. In this case, repeated testing provided docu- mentation of both the cognitive repercussions of his psychiatric disturbance and the effects of psychotropic medication on his cognitive fune- tioning. This case demonstrates the value of re- peated testing, particularly when one Or an- other aspect of the patients behavior appears to he in liux. Had testing been done only at the time- of the second or third examination, a very distorted impression of the pa‘tient’s cognitive status would have been gained. Fortunately, since the patient was in a research project, the :first examination data were awailahle to cast doubt on the validity of the second and third sets of test performances. and therefore the fourth examination was given as well. Brain damaged patients must have Factual information about their functioning to under- stand themselves and to set realistic goals. yet their need for this information is often over- looked. Most people who sustain brain injury experience changes in their self—awareness and emotional functioning; but because they are on. the inside, so to speak. they may have difficulty appreciating how their behavior has changed and. what about them is still. the same. These 8f23r’2EIElEI 18:82 l El??2EufilEl?l3 PiliGE Elli-“lid 12 THEORY AND PRACTICE OF NEURDF’SYCHOLOGICAL ASSESSMENT rnisperceptions tend to heighten what mental confusion may already be present as a result. of altered patterns of neural activity. Distrust of their experiences, particularly their memory and perceptions, is a problem shared by many brain damaged persons, prob- ably as a. result of even very slight disruptions and alterations of the exceedingly complex neural pathways that mediate the cognitive functions. This distrust seems to arise from the feelings oF strangeness and confusion accom- panying prenousiy familiar habits, thoughts, and sensations that are now experienced dif- ferently, and from newly acouired tendencies to make errors. The Self-doubt of the brain in~ jured person, eitcn referred to as perplanlty, is usually distinguishable frrnn neurotic self- doubts about life goals, values, principles, and so on, but can he just as painful and emotion- ally crippling. Careful reporting and explana- tion of psychological findings can do much to allay the patient's anxieties and dispel confu- SIG“, The following case exemplifies both paiients’ needs For information about their psychological status and how disruptive even mild experi- ences of perplexity can be. An attractive, unmarried 24-year-old bank teller sustained a brain concussion in a car accident while on a skiing trip in Europe. She appeared to make an uneventful and practically complete recovery, with only a little refidual Facial numbness. When she came home, she returned to her old job but was unable to perform acceptably although she seemed. capable of doing each part oFit well. She.- losl: Interest in outdoor sports although her coordination and strength were essentially unimpaired. She became socially 1Witliiilravvi‘l, moody. mornse, and dependent. A psychiatric: consultant diagnosed depression, and when her unhappiness was not diminished by coun— seling ar antidepressant drugs, be administered shock treatment. which gave only temporaiy relief. While waiting to begin a second course of shock treatment, she was given a necropsychclogical ex— amination at the request of the foreign magistrate who was responsible For awarding monetary com- pensation For her injuries. This examination dem- onstratcd a small but definite impairment of imme» diate memory. concentration. and conceptual tracking. The patient reported a pervasive sense of unsureness which she expressed in hesitancy and doubt about almost everything she did. These [ecl- ings of doubt had undermined the young woman’s trust in many of her prmioiisly automatic responses, destroying a lively spontaneity that was once a vary appealing feature of .her personality. Further, like many postconcussion patients. she had. compounded the problem by interpreting her inner uneasiness as symptomatic of "mental. illness." and psychiatric opinion confirmed her fears. Thus, while her cog— nitive impairment was not an obstacle to rehabilita- lion, her bewildered experience of it led to disssn trons changes in her personal life, A clear explanation of her actual limitations and their impli— cations brought immediate relief' of anxiety and set the stage for sound counseling. The concerned family, too, needs to lcnow their patients psychological condition in order to respcmcl appropriately (J. G. Allen et al.., lass,- u. N. Brooks, 1991,- Lezak, lasaa). Fam— ily members need to understand the patient's new, often puzzling, mental. changes and what may be their psychosocial repercussions. Even quite subtle defects in motivation. in abilities in plan, organize, and carry out activities, and in sell-monitoring can compromise patients' capacities to earn a living and render them so- cially dependent. Moreover, many brain daun- aged patients no longer fit easily into family life as their irritability, self-eenteredness, impulsiv— ity, or apathy create awesome emotional bur- dens on. family members, generate conflicts be- family members andwiih the patient, and Strain Family tics. often beyond endurance (lsezak, itil'da, lfltllih). 3. Rehabilitation and treatment nucleation. Today, much more of the work of neuropsy— ohologists is involved in treatment or research on treatment, an involvement that is expanding rapidly with increased recognition of the needs of patients and their families and of the use- fiilness of neuropsychological interventions {13. W. Ellis and Christensen, 1989', Lezalt, pars-aim, 1989a; Newcombe, 1985; Sohlberg and Mateer, 1989). This shitting focus creates ad- ditional assessment demands as carefiil, sensi— tive, broad-gauged, and accurate neuropsycho- 8832332885 18:82 El??2E~48?8 PihGE 8?r'l8 OGICAL ASSESSMENT rted a pervasive sense of messed in hositancy and sing she did. These Feel- ined the young woman’s Jsly automatic responses, sity that was once a. very larsnnality. Further. lilcc its, she had compounded g her inner uneasiness as llness." and psychiatric rs. Thus, while her cog— m obstacle to rehabilita- ience of it led to disas— ierscnal life. A clear citations and their impli- relief of anxiety and Set ing. ', too. needs to know cal condition in order y (I. C. Allen or at. ; Lezalc, 1988a). Fam- derstand the patient’s ital changes and what l repercussions. Even motivation, in abilitiea fly out activities and :ompromise patients' ; and render them so- on, many brain dam- t easily into family life ante-redness. impulsiv- some emotional. bur— generate conflicts he- md with the patient, on beyond endurance resonant evaluation. re work of necropsyu rcstment or research lent that is expanding :ognificn of the needs lilies and of the use- logical, interventions 'ensen, 1989; Lezak, a, 1985,- Sohlberg and. leg focus creates ad- nds as carol-bl. sensi- qurate neuropsycho- THE PRACTICE OF NEUROF’SYCHOLDGICAL ASSESSMENT 13 logical assessment is a necessary foundflfiflfl on which appropriate treatment of organic brain dysfunctions can be based. In rehabilitation and retraining programs, treatment and care responsibilities are often shared by professionals From many disciplines and their subspecialties, such as psychiatrists, speech pathologists, rehabilitation counselors, occupational and physical therapists, and visit- ing nurses. They need current appraisals of pa- tients’ neuropsychological status so that they can. adapt their programs and goals to their pa- tients’ changing needs and. capacities. Neuro- psychclcgical. assessment of patients' defective behaviors can provide the rehabilitation ther~ apist with a description of the patients’ mental capabilities. In addition, it can give an often more important analysis of how patients fail that will tell the therapist how patients might improve their performances in problem areas (cg, Porch and Ilaaland, 1984; B. A. Wilson. 1986). Ways in which the results of detailed nouropsychological analyses of behavioral def- icits may be applied to rehabilitation problems have been. effectivon demonstrated by Leon- ard Diller and his group (1974; Dillcr and Weinberg. 1977; Institute of Rehabilitation Medicine, 1930, 1981. .1982. See also R. F. Co- hen and Mapcu. 1988; Kreutzer and Vlr’ehrnarrn 1991, possim: Sohlberg and Mateer, 1989). Such analyses may also indicate whether a pa— tient can benefit from psychotherapy, particu- lar behavioral training techniques. and gener- ally acccptcd counseling approachcs (cg, Ml'lcy. lefi; lnn‘in. 1972; Sundet et al.. 1988; R. I... Wood, 1986. See also Kasanialc and Berta, 1993, for a dismissitm oil the cost-effectiveness Of neuropsychclogical evaluations of rehabili- tation patients). A 30-year—old laWycr. rcccntly graduated in the top ten pmcenl.‘ OF his law school. class, sustained a rup- tured right anterior communicating artery aneu- I'ysm. Surgical intervention stopped the bleeding but left him with memcn'impairmcnts that included dif- ficulty in retrieving stored information when search- ing for it and very poor prospective memory (i.e., remembering to remember some activity originally planned or agreed upon. For the Future, or remem- bering to l-zcep track or and use needed tools such as memory aids). Other deficits associable to Frontal lobe damage included diminished emotional capacity, empathic ability, self-awareness. sponta- neity, drive. and initiative-taking; impaired social judgment and planning ability; and poor self-moni- toring. Yet he retained verbal and academic slcills and knowledge. good \dfiuospatial and abstract rca- Rolling abilities, appropriate social behaviors, and 1115 motor system was intact. Following repeated Failed efforts to return to the practice Di" law. he entered a recently organized re- habilitation program directed by a therapist whose experience had been almost exclusively-with aphasic patients. The program emphasized training to en- hance attentional. functions and to compensate for memory deficits. This trainee learned how to ltecp a memory diary and. notebook, which could support him through most of his usual. activities and respon- sibilities: and he was appropriately drilled in the nec- essary memory and note-taking habits. What was overlooked was the overriding problem that it did not cosm- tn him. to remember what he needed To remember when he needed to remember it. {When his car keys were put aside where he could see them with instructions to get them when the examination was completed, at. the end. of the session he simply left the examining room and did not thinlc of his keys until. he was outside the building and I asked ifhc had Forgotten something. He then' demonstrated a good recall of what he had left behind and where.) One weelr after the conclusion of this costly hm- month long program. while learning the route on a ne=wjoh deliveringin-house mail, he laid his memory book down somewhere and never llmud it again“— nor did. he ever prepare another one. For himself :lc- spite an evident need For it. An inquiry into the re- lmhilitadon program diSUlDSBd a lack of appreciation oi" the nature of Frontal lobe damage and the needs and limitations ni' persons With brain injuries of this kind. The same rehabilitation service provided a virtu- ally identical training program to a 42-year-old civil engineer who had incun‘cd severe attentional and memory deficits as a result of a. rear-end collision in which the impact to his car threw his head Forcihly hilch onto the head rest. This man was keenly and painfully aware this deficits. and he retained strong emotional and motivational capacities, good social and practical judgment, and nhilitics For planning, initiation, and self-monitoring. He too had, excellent BSFZBIQBBE 1E1: El? El??2E~4El?l3 F'ifliGE E18318 H THEORY AND PRACTICE OF NEUROPSYCHOLOGICAL ASSESSMENT verbal. and visuospat-ial loiowledgc and skills, good reasoning ability. and no motor deficits. For him this program was very beneficial as it gave him the at- tentional training he needed and enhanced his spon— taneously initiated efforts in compensate for his memory deficits. With this training he was able to continue doing work that was similar to what he had done before the accident, only on a relatively sim- plified level and a slower potions-lance schedule. With the ever-increasing use of rehabilita- tion and retraining services must come quesn tions regarding their worth. These services tend to be costly, both monetarin and in ex- penditure ofprofesaional ti me. Consumers and referring clinicians need to ask whether a given service promises more than can be delivered, or whether what is produced in terms oi" the patient's behavioral changes has psychological or social value and: is maintained long enough to Warrant the costs. Here again, neuropsycho- logic-cl assessment can help answer these ques- tions (sicker, 1986; Ben-Yishay and Diller, 1983; Solilherg and Meteor, 1989). 4. Research. Neuropsychologieal assessment has been used to study the organization of hrain. activity and its translation into behavior and in. investigations oi specific brain disorders and behavioral disabilities. Research. with neu- ropsychological assessment techniques also in- volves their development, standardization, and evaluation. The precision and. Sensitivity of neuropsychologieal measurement techniques make them valuable tools lot investigation. of small, sometimes quite suhtle behavioral alter- ations, such as those that may follow cer- tain neurosurgieal procedures or metabolic changes. Neuropsychological research has had a very direct influence on the practice of clinical neu- ropsyehology {e.g., see L. Costs. 1988.- Lezalt. 1938c,- Rourke, Fisk. Strang, and Gates, 1981]. Many of the tests used in neuropsychological evaluations—such as arithmetic tests or tests for visual memory and learning—were origi- nally developed for the examination ol‘ normal cognitive Functioning and were reealihrated l'or neuropsychologioal use in the course of re- search on brain dysfunction. Other assessment teeh.niques-—-as for instance. certain tests of tactile identification or concept formation—— were designed specifically for studies of brain dysfunction. Their often rapid incorporation into clinical use attests to the very lively ex- change between research. and practice. This eit- change works especially well in necropsychol- ogy because clinician and researcher are so often one and. the same. Usually neuropsychologi cal studies serve more than one purpose. Even though the examina- tion may be initially undertaken to answer a single question such as a. diagnostic issue, the neuropsychologist may uncover vocational or Family problems, or patient care needs that have been overlooked, or the patient may prove to he a Suitable candidate for research. Integral. to all psychological assesament prone»- dures is an evaluation oli'the patient’s needs and. circumstances from a psychological view- point. When. indicated, the neuropsyehologist will enlarge the scope of inquiry to include newly defined problems, as well as those stated in the referral. Should a single examination be undertaken to serve all three purposes—diagnosis, patient care, and researches great deal of data may he collected about the patient and then ap- plied selectively. For example. the examina— tion of patients complaining of immediate. memory problems can be conducted to answer various questions. A diagnostic determination oi whether immediate memory is impaired may only recluire finding out if they remember sigitlillcnutly ‘l‘c‘it’m‘ words of" a list and. mnnl'nirs of a series than the slowest intact adult. To un~ derstand how they are ails. cted by memory dys- function, it is important to know the number of words they can remember and. under what conditions. the nanire of their errors, their sen.- sitivii-ies and reactions to their peirl'ormanCes, and the effect of their disahilities on their days to-tlay activities. Research might involve stud}L ing immediate memory in conjunction with blood sugar levels or brain watt: tests. or com— paring the way they perion to that of patients with other kinds oi" memory complaints. Necropsychological assessment undertalrei-i for legal proceedings illustrates the uselhlness of multipurpose studies (Doers and Carlin. BSKQBKQBBE 18: iLDGICAL ASSESSMENT 1r concept formation— ;ally for studies of brain ten. rapid. inocrporation .‘S to the very lively ex~ ch and practice. This es- ly well in neuropsychol- and researcher are so e. g'ical studies serve more in though the examinap undertaken to answer a s a diagnostic issue, the r unmver vocational or iatient care needs that I i. or the patient may candidate for research. gical assessment proce- of the patient's needs 11 a psychological. viewa- . the neuropsycliologist = of inquiry to include 5, as well. as those stated ninetion. be undertaken. arses—diagnosis. patient great deal of data may a Patient and then ap- example, the examine:- plaining of imi‘nedia‘te be conducted to answer iagnostic determination 2- memory is .impairmi :‘E 011tif1‘l‘lr‘.y rmneml‘wr is of a list and numbers vest intact adult. To un- flected by memory dys- It to ltnow the number ember and. under what IF their errors. their sen- to their performances, ijsabilities on their day- .‘ch might involve study- .y in conjunction With rain wave tests. or com- form to that of patients moor Cornplaints. hsessment undertaken [its ates the usefulness Doerr and Carlin, 82 jig t. stats“ El??2E~4EIT-"S 1991; Dywan, Kaplan. and Pirozzolo, 1991; Ne- metb. 1939. 19933; S. Taylor and Elliott. 1989). It has become quite commonplace in personal injury actions. in which monetary compensation is sought for claims ot‘bodily in- jury t nd loss of function, for lawyers to request neuropsycbological examinations of the elairm am. In such cases. the neurepsyehologist usu- ally examines the claimant: to evaluate the type. and amount of behavioral impairment sus- tained and to estimate the claimant's rehabili- tation potential and the extent of any need for future care (Kreutzer, Hards-Manwitz, and. Myers. 1990; Kurlycbcek, 1934a; Maeartney— Filgate and Snow. 1.990). Occasionally. the reu quest tor cornpensation may hinge on the neu— ropsyobologist‘s report. In criminal cases, a neuropsychologist may assess a defendant when there is reason to sus- pect that brain. dysfunction contributed to the niisbehaidor or when there is a question about: mental. capacity to stand. trial. The case of the murderer of President: Kennedy’s alleged as- sailant is perhaps the most famous instance in which a psychologist determined. that the de- -Fentian.t's capacity For judgment and sell-con- trol was impaired by brain dysfunction (J. Kap— lan and Waltz. 1965). Interestingly. the possibility that the defendant. jaclr Ruby, had psychomotor epilepsy was first raised by Dr. Roy Selniter's interpretation oi the psycholog- ical test findings and was subsequently con- lli'rrtod by Chmrt)Eileen)hrrlrjgmpizin: (EEC) tl‘iniin Wave) studies. At the sentencing stage of a criminal proceeding, the neuropsychologist may also be asked. to give an opinion about treatment or potential for rehabilitation of a convicted de'tondant. What might the :tiiture hold tor neuropsycho- logical assessment? From n.r:~.uropsychologys past history it is easy to predict a continuing proliferation of tests. batteries. nontest assessr merit approaches, and technical refinements For many of these assessment tools. If present trends auger the throne. we can expect more and more varied. applications of neuropsycho- logical assessment in: both clinical and theoret- ical research in medicine, the neurosciences. educatirm. and the social sciences as well. PhGE BEIle THE PRACTICE OF NEUROPSYClrlOLOGICAL ASSESSMENT 15 Some specific trends will probably be of ma- jor importance in the near Future. Computer- ized assessment‘ is rapidly proliferating; appli- cations are being dew-teed and elaborated in test administration. test scoring and "number crunching." and test interpretation, including the generation at diagnostic categories and lo; ealization prohi-ibilities { K. M. Adams and Hen- ton. .lQii'i’). Growing concern about the validity of test and battery based interpretations and. predic- tions has led to some innovative responses to this problem. In hopes of improving predic- tions of real-life outcomes following brain in.- jnry and brain disease. some investigators are developing evaluation tecliniques—fimcttonal assentertains—titer substitute practical perfor- mance criteria for Formal tests (Anti-"GT. 1959; M. Brown or at. 1983: PonsFerd. 1986). In- creasingly sophisticated correlative studies rem lating behavioral. neuroradiographic. neuron physiological. and. biochemical measures will also improve our ability to predict the behav- ioral. consequences oi brain. disease and. brain. dysfunction (see also jernigan, 1990: Rourke. 1991). Specialized testing programs are being designed to examine specific classes of deficits. such as memory impairment (Larrabee and Crook. 1989a and. b.- CA.) Wilson, Cockbum. and Baddeley. 1985. 1989) and diminished so- cial competency (W'ang and Ennis, 1986). Heinrich (1990) points out that in neuropsy- chology ll'lli: validity and applicability of tests i'tl'll'l .‘-‘I..'~'.‘it'_‘ifii'ne1'ill programs may vary according to the purposes of the assessment. He distin- guishes three major frames olireierence within which neuropsychologieal validity and reliabil- ity can be evaluated: medical. for diagnostic purposes; ecological mmpet‘ence. tier arm-sel- ing. planning, and placement leg, job. living situations); and rehabilitation, to direct and evaluate rehabilitation. programs. To solve the validity question. still others have turned to the establishment of comput- "Hy virtue of both its highly technical nature and the large number of tests and adjunctive applications already avail- Ilhli.‘ for computer ‘1st computerized assessment cannot be dealt wlth in this book. excels: in some [ii-Irtieulat instances In which the material presented here and its computerised ommterpart naturally overlap. 517372848738 8832332885 18:82 erized data banks to provide demographically well-defined normative data on many tests in common use fog“ Bernstein, 1985; I-Ieaton= Grant. and Matthews, 1991; see also L. Costs, 1988}. Closely releied to validity questions and normative solutions is a growing awareness of the need. to develop appropriate assessment techniques and. test norms for the older“ age PflGE 18318 15 THEORY AND PRACTICE OF NEUROPSYCHDLDGICAL ASSESSMENT groups that. by and large, are stifl neglected by test—makers (Lezeh, 1987; Penn, 1983, pessim; Van Corp, Satz, and Mitmshine, 1990}. These trends do not seem to portend radical changes in neuropsyehologico] assessment. but rather a. healthy evolution in response to the ever more varied demands made on it and the ever greater sophistication of these who use it. ...
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This note was uploaded on 03/26/2008 for the course PSYCH 71 taught by Professor Kuperberg during the Spring '08 term at Tufts.

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PSY71 - Neuropsychological Assessment - 8832332885 18:82...

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