Neuropsychology Ch 3

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psychosomatic

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related to increased stress

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almost half of clinical neuropsychologists

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work in private practice

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24% of clinical neuropsychologists work in

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medical schools

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11% of clinical neuropsychologists

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work in rehabiliation hospitals

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5% of clinical neuropsychologists work

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in unviersity settings

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5% of clinical neuropsychologists work

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in Veterans Affairs (VA) medical centers

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average clinical neuropsychologist

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devotes 63% of their professional time to neuropsychology, has 12 years of experience practicing, is 45, and is male

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"generalist"

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grounding in clinical psychology with expertise in clinical neuropsychology

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percents seen for rehab, neurologic, psychiatric, learning disabled, forensic, and dementia patients

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29%,21%, 20%, 10%, 7%, 5%

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neuropsychologists often pigeonholded as

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reductionistic "lesion detectors"

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neuropsychologists role in diagnostic, treatment implication, assess school/work capacity, and rehabilitation

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56%, 16%, 8%, and 7%

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neuropsychological evalulation is

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an objective, comprehensive assessment of a wide range of cognitive and behavioral areas of functioning, which the neuropsychologist typically integrates with intellectual and personality assessments and evaluates within the context of CT and MRI scans.

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psychometrics is

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the science of measuring human traits or abilites, is concerned with the standardization of psychological and neuropsychological tests

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standardized test is a

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task of set of tasks administered under standard conditions and designed to assess some aspect of a person's knowledge or skill.

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reliability is

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the stability or depedability of a test score as reflected in its consitiency on repeated measurement of the same individual

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validity

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meaninfulness of specific inferences made from the test scores: does the test measure what it is supposed to measure?

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construct validity

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test score measures abstract, psychological characteristic: important for demonstration of the cognitive or functional abilities a teast measures

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content valdity

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pertains to the degree to which a sample of items or tasks makes conceptual senswe or represents some defined psychological domain.

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criterion validity demonstrates

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that scores relate systematically to one or more outcome criteria, either now (concurrent validity) or in the future ( predicitve validity)

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false positive (type I error or false alarm)

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case in which a neuropsychological test erroneously indicates a pathologic condition

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Base rate

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frequency with which a pathologic condition is diagnosed in the population tested

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Valid test predicts pathology best when....

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base rate is equal to 50%

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false negative (type II error or miss)

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when neuropsychological test incorrectly concludes absence of pathology

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achievement test

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how well an individual profits from past experience

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aptitude test

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measures an individuals liklihood of success in the future

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behavioral-adaptive scales

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examines what an individual habitually does, not capability of doing

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intelligence test

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complex composite of verbal and performance ability that is affected by achievement and aptitude

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neuropsychological tests

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sensitive to brain damage/indicates brain pathology

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personality test

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measures emotional states, interpersonal relationships, and motivation.

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vocational inventory

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measures opinions and attitudes that indicate an individuals interest in different fields of work

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cystallized functions

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dependent on cultual factors and learning

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fluid functions

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culture free and independent of learning

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test battery

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number of different tests that address different areas of brain-behavior functions

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Lethargy

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sometimes a symptom of depression, sometimes a symptom of brain damage

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Most basic aspect of cognition

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alertness

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orientation

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patient's basic awareness of the world around them

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Orientation in neuropsychology

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knowledge of self, time (date), and place

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"oriented times three"

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oriented in relation to self, time (date), and location

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Galveston Orientation and Amnesia Test (GOAT)

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short mental status examination that measures extent and duration of confusion and amnesia after a traumatic brain injury

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Glasgow Coma Scale

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simple, repeatable neuropsychological test

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scored from 1-100 (75 or better indicting intact orientation and patient's ability to undergo neuropsychological testing)

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scores on Galveston orientation and amnesia test (GOAT)

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sensation

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elementary process of stimulus exciting a receptor resulting in a detectable experience in a sensory modality

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perception

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depends on intact sensation and is the process of "knowing" a stimulus

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perceptual process steps

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1) arousal 2) sensation 3) perception

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stereognosis

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recognition of object by touch

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Halstead-Reitan Neuropsychological Battery includes a senosry-perceptual examination that tests

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finger agnosia, skin writing recognition, and sensory extinction in the tactile, audtitory, and visual modalities

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sustained attention

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paying attention to something over a prolonged period

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selective attention

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paying attention to more than one thing at a time

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attention span test

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examiner asks patient to attend to various verbal stimuli, then repeat them.

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standardized tests of attention

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Symbol Digit Modalities Test (SDMT),

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Symbol Digit Modalities Test (SDMT)

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requires respondent to fill in blank spaces with the number that is paired to the symbol above the blank spacfe as quickly as possible for 90 sec.
-primarily assesses complex scanning, visual tracking, and sustained attention

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d2 Test of Attention

Back 52

timed test of selective attention/ standardized refinement of a visual cancelation test. measures processing speed, rule compliance, and quality of performance

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most frequently used test of attention in Europe/ developed in 1962 in Germany and Switzerland as an assessment tool for driving efficiency

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d2 Test of Attention (translated into 4 languages)

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graphomotor skills

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assess the ability to copy shapes with increasing degrees of difficulty

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motor apraxia items

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assess the intactness of common motor sequences.

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apraxia

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inability to perform purposeful sequences of motor behaviors

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motor apraxia or ideomotor apraxia

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inability to access a stored motor sequence or inability to relay that information to the motor association ctx.

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motor apraxia test

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"show me how you would make a telephone call"

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grip strength test

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squeeze dynamometer as hard as you can

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finger oscillation or finger tapping test

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patient taps as rapidly as possible with the index finger on a small level attached to a mechanical counter

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deficits in motor component of writing, simple reading, speeling skills

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dysgraphia, dyslexia, spelling dyspraxia

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Token Test (easily passable for anyone without aphasia past the 4th grade)

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a simple but effective test of auditory comprehension in which the patient is asked a number of commands (such as "Touch the small yellow circle") that relate to plastic tokens

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Controlled Oral Word Association (COWA) test

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assesses subject's ability to use expressive speech. Measures verbal fluency by asking subject to name as many words as possible that start with a letter (within 60 seconds a graduate student should be able to name 15 words that start with letter R) using letters C, F, and L by frequency respectively

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Bender Gestalt test consists of

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nine geometric designs which the patient must reproduce exactly. It measures visuospatial construction and is sensitive to changes in neuropsychological status, particularly visual-graphic disabilities.

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Rey (1941) and Osterrieth (1944) devised another drawing test to investigate perceptual organization called the

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Rey-Osterrieth Complex Figure Test. It presents subject with an intricate figure to reproduce.

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immediate/ delayed verbal memory

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list of words to be repeated now/ after 30 minutes

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Delayed visual memory

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patient chooses previously shown figures

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contextual/logical memory immediate/delayed

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testing the patient's free recall ability by reading story and having patient recite it freely.

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Wechsler Memory Scale (WMS; first introduced by Wechsler in 1945) now in its thrid revision (WMS-III) is sensitive to memory deficits associated with aging

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seven subtests which include personal and current information, orientation, mental control, logical memory (recall of two stories), digit span, visual reproduction, and associate learning (requiring verbal retention)

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transfer of learning

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ability of a patient to use abstract reasoning to understand concepts

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The Trail Making Test B (part of the Halstead-Reitan Neuropsychological Battery)

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requires participant to draw lines to connect consecutively numbered and lettered circles by alternating the two sequences (necessitates complex visual scanning, motor speed, mental flexibility, and attention)

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Wisconsin Card Sorting Test (WCST)

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widely used to study "abstract behavior" and "shifting sets" by giving patient 64 cards with 4 symbols (triangle, star, cross, circle/ green,red, yellow, blue) and ask patient to sort them one by one based on feedback from examiner

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Tower of London-Drexel University (TOL^dx) as a neuropsychological meausre of executive planning and problem solving by

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measuring

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executive planning

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involves the ability to conceptualize change, respond objectively, generate and select alternatives, and sustain attention

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frontal lobes

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support executive planning in systematic interaction with other cortical and subcortical structures

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Tower of London-Drexal University (TOL^dx) setup

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two identical tower structures, one for examiner and one for subject, with three pegs of descending lengths and three colored beads that the patient can place on the pegs

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Tower of London-Drexal University (TOL^dx) rules

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only move on bead at a time, and do not place more beads than fit on each peg

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Tower of London-Drexal University (TOL^dx) sensitive to complex set of cofnitive processes including...

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planning computations, working memory, mental flexibility, attention allocation, and response inhibition

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malingering tests and exaggeration tests assess

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symptom validity

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patients with right parieto-occipital stroke often have

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limited insight into their condition

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transfer of learning

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ability of a patient to use abstract reasoning to understand concepts

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malingering according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

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"intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives"

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Test of Memory Malingering (TOMM)

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Useful for detecting memory malingering

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neuropsychological exam better than imaging for...

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providing info about how brain damage affects behavior and in diagnosing diseases that cant be diagnosed with imaging (AD, ADHD, mild head injury, etc.)

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What neurologic goal dominated clinical neuropsychology through the 70's?

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Detecting and classifying lesions

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the clinical neuropsychologist is primarily concerned with generating what in regards to the patient?

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interpretive hypotheses (lesion location, extent, effects, etc.)

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pioneered use of the standard battery approach

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Halstead (1947) and Reitan (1966)

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advantages to standard battery approach

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1) all subjects evaluated for all basic neuro abilities
2) use normalized objective data to diagnose individuals
3) easy to entry level students to perform because it doesnt require test selection based on symptoms
4) good for empirical data in different research programs

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drawbacks to standard battery approach

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1) takes a long time
2) causes fatigue/loss of motivation
3) neuropsychologist has little contact with patient/ lose of qualitative analysis
4) tests within battery may yield poor results

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Halstead-Reitan neuropsychological battery does not contain

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a memory test

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Hooper visual organization test

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name or write down name of cut up objects/ measures perceptual integration (RH)/ score below 20/30 indicates organic brain pathology

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Problem with Hooper visual organization test

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patients with RH stroke fail not because of perceptual integration problems but because of an impairment in naming objects

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critique of battery approach

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suggest that why a patient fails a test is as important as them failing the test

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battery approach not always suitable for patients with

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peripheral deficits (vision, motor, etc.)

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55% of neuropsychologists favor

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flexible, modified battery approach

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process approach (hypothesis approach)

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neuropsychologist should adapt each examination to the individual patient

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principle developers of the process approach

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Alexander Luria and Edith Kaplan

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advantages of the process approach

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1)acknowledges the individual nature of the patient's deficits and seeks to adapt the exam to this individuality
2)can concentrate on those areas the neuropsychologist sees as most important for the patient while ignoring unimportant areas for prognosis

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flexible/process approach emphasizes

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in what manner a patient fails or succeeds in a specific cognitive task

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disadvantages of process approach

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1)exam may selectively confirm clinicians opinion because of examiners bias.
2)may miss important cognitive deficits

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not unusual for patient to have

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secondary deficits that appear unrelated to primary referral problem

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not unusual for major stroke patient to have

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small, secondary disorder of cerebral circulation

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Paul Meehl

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preeminent psychodiagnostician and former president of APA, addressed the complex decision-making process involved in psychological assessment.

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Who wrote "when shall we use our heads instead of the formula?" (1973).

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Paul Meehl- addressing the rationale for when to use more empirical (psychometric) compared with clinical (qualitative) approaches to psychological assessment.

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Meehl believed neuropsychologists should use their "heads" when?

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very seldom, unless the case is obvious

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48% of neuropsychologists report

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using parts of both approaches

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26% of neuropsychologists

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use process/qualitative approach only

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22% of neuropsychologists use

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fixed battery/psychometric approach only

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site, nature, and severity of the injury/disease process, permorbid personality, and a host of other moderating variables afffect

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afffect neuropsychological test performance

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several levels of analysis

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1)level of impairment
2) pattern of impairment
3)lateralizing and localizing signs
4) qualitative observations

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normative data

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compares the patients score on a test to an expected score

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cutoff score

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patient scoring worse than this score is labeled as impaired; patient scoring better is labeled as within normal limits

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test sensitivity

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allow for diagnoses of abnormal cognitive abilities but include many false positive errors (low cutoff score)

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test specificity

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assess more general areas of cognitive functioning including sustained attention or immediate memory/ but may miss patients who have impairments outside specific areas (false negatives)

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standardized score

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deviation score from the mean

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normal distribution

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68.2% of cases fall between one standard deviation from mean,
95.4% of cases fall between 2 SD from mean,
99.7% of cases fall within 3 SD from mean

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sat mean and SD

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500 +/- 100

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percentile score

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percentage of people who scored at or below score you obtained

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standard score (SS) calculation

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subtract the mean from a normative group for a test from the person's actual score. divide result by the SD of scores, multiply this result by SD and add the mean

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Z-score mean/ SD

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0 and 1

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Sten score mean and SD and tests used

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5 and 1
16 personality factors

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scaled score mean / SD/ tests used

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10/ 3/ Wechsler subtests

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T-Score mean/ SD/ tests used

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50/10/ Minnesodta Multi-phasic personality inventory, many norms

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Standard score (SS) mean, SD, tests used

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100, 15, Wechsler Intelligent Quotient scores

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standard score should not be used on tests that are

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not normally distributed

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Deficit measurement is

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standardized and group oriented (patient's deviation from mean)

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Howard Gardner, Harvard psychologist said neuropsychologists should not ask

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"How smart is this person", but "how is this person smart?"

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deficit measurement approach measures

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patients score on two tests: one test highly sensitive to brain damage (problem-solving task), and one insensitive to brain dysfunction (factual language).

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insensitive tests to brain dysfunction test

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patients ability before brain injury occured

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pattern analysis

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examines the relationships among the scores in a test battery

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early stage Alzheimers dementia pattern analysis

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neuropsychologists would expect a deficit in memory functioning compared with performance of verbal tests.

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advantages to differential score method and pattern analysis

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recognizing that each individual starts at different level of performance and avoids misclassifying all people with low ability as "brain injured"

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sources of error in differential score method and pattern analysis method

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1)sensitive test may fail to reflect the impairment present
2)brain injury may lower a score on an insensitive test because all abilities depend on the brain

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lateralizing signs

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if one side of body performs significantly worse than other, the opposite hemisphere may have damage/ subtract scores from both sides of body to find difference score

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weaknesses of lateralizing signs

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may yield inaccurate conclusions when an injury involves both hemispheres, or when an injury to the spinal cord is involved because such injuries may also cause lateralized deficits

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pathognomonic signs

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method that clinical neurologists commonly use to diagnose patients

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pathognomonic (Greek "fit to give judgment)

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specific disease or pathologic condition can be detected

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medical pathognomonic model

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causal model in which specific signs stem either from a specific medical condition or from the disease itself

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medical pathognomonic model weaknesses

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if the signs from the medical exam do not fit precisely, or are transient, no substantive diagnosis can be established, so no treatment can be offered