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University of Toronto Scarborough
Konstantine Zakzanis

Clinical Neuropsychology - Lecture 1 Tuesday, January 11th, 2011 Chapter 1 - The Practice of Neuropsychological Assessment About the quote by Lezak: As a clinical neuropsychologist, were interested in understanding behaviour (more specifically cognitive function: memory disorders, executive disorders, etc.). However, this definition is dated, there is so much still to be learned and describing the limitations it presents. To understand where its going, we need to see where it came from; therefore history is necessary to cover. Early demonology: why did this occur?, why would they drill a hole in peoples skulls? There was a predominant view that demonology was responsible for mental health deficits. However, when they did this, they caused brain damage, increasing the abnormalities and mental deficits. About witch hunts: looking for people they thought were possessed, who displayed different symptoms from typical mental health disorders. People who survived the dunking were considered witches and beheaded, people who did not were dead anyway. This was one of the first ways of administering tests to deduce the possession of impairments in mental health. The same kind of algorithmic thinking occurs today. Franz Joseph Gall - a direct bearing on where neuropsychology is going today. His basic tenets (of the mind) based on his observations back in the day when he was a teacher. 1: yes, we consider this; 2: yes, it has been determined that different parts of the brain are used for different functions; 3: yes; 4: kind of, there is conflicting evidence; 5: probably not, but what he was hinting to is maybe there is something important in the area of the brain in relation to someone who has a higher aptitude in some area; 6: no, he kind of fell apart when he started to lean towards this tenet, leading to phrenology. Phrenology: not so far from what Gall was doing with this, we have the general idea of the modern day fMRI. Video: Quack Gallery: Phrenology & Psycographs. 2 important things to take from it, 1) modern brain mapping has some lineage back to Gall and his tenets now true today and 2) its difficult to assess someone using a test like this to be able to determine or extrapolate toward their real world behaviour. Asylums: locked up like inmates or zoo cages, they were horrible experiences for anyone with these disorders. There were some real keen neurologists working in these hospitals, like Paul Broca. Broca: He really was the first person to truly relate a cognitive disorder back to the brain that still remains true today. He had a patient, Tan, who he found to have a lesion in his left frontal lobe. He deduced that this led to the unability to speak fluently but able to comprehend. He found more patients with the same symptoms who, when they died, looking at their brains, also had lesions in the same area. This area became known as Brocas area and the disorder now more commonly known as Brocas aphasia. Wernicke: After Paul Broca published his study, this neurologist came along. He found a patient who had symptoms completely opposite of Brocas aphasia. Where the person was fluent in their speech but could not comprehend. Notice that these aphasic disorders are not so clear-cut, and so it is difficult to assess patients with these symptoms. Some tests have been developed to determine which one specifically they may suffer from. This leads to executive disorders... Phineas Gage: this was the first time that a brain disorder was related to a change in personality. He became a classic study in terms of understanding of how the brain could give rise to difficulties at a higher level of cognition, beyond things like speech problems. Psychoanalysts began to take over (ie., Freud, etc.) and these studies were forgotten. However, when the war came about, a lot of men came about with brain injuries. a neurologist, Geshwind, in Boston, saw many patients with these cognitive difficulties that we saw previously. He was the one to go back in literature to see if these symptoms had ever described, and he came across the studies of Broca, Wernicke, and Harlow. His students included Lezak, Kaplan and Warrington. The fact that these people are somewhat connected to us demonstrates how young this science is... One of the first validated neuropsychological tests was the clock drawing, displaying visual neglect. They recorded normative data (important term! the science that neuropsychology is based on...) since they didnt have the instruments we have today. They mapped the damaged areas and the corresponding dysfunctions. Tests were described to assess lateralization (motor tests: pegboard tests), aphasia (Boston diagnostic aphasia test), Boston naming test: individual ability of the patient to name pictures shown to them on cards. There are now a plethora of tests used in neuropsychological assessment today. Again, its a very young science. (2 main take home points!) Things beyond brain injury, such as depression are also relevant, and so clinical psychology plays a role, along with a few other fields. (Be familiar with these!) The practice NPA: - a clinical neuropsychologist is someone who earns a PhD in clinical psychology who specializes in neuropsychology; also has to do a post-doctoral residency in neuropsychological assessment - they can diagnose psychological disorders as well as neuropsychological disorders, but a clinical psychologist could not - they could be involved with private practice, in a hospital setting, their primary role is diagnostic - there is a huge need for NPAs, because of what can be deduced from these, and the science behind it, it also under weighs the majority of the treatment that would be applied This course will focus mostly on the diagnostic science of clinical neuropsychology. What precipitates a NPA? 1 - referral by a GP or neurologist (clarification of diagnosis, ie. does this person have Alzheimers or is it just old age?) 2 - what is the breadth and severity of cognitive impairment and how does that affect their ability to engage in activities in their daily living (do they require supervision because of this?) 3 - ie., testing someone visual ability if their verbal is impaired, and increasing their ability to compensate for the deficit 4 - ie., prescribing Ritalin to a child with ADHD 5 - the neuropsychological signature that characterizes the disorder 6 - the most needed in recent days, neuropsychology has focused on issues such as malingering, people emulating disorders, feigning a brain injury Rey-Ostierieth Complex Figure: cognitive functioning, visuospatial ability, which relates to the parietal lobe. In this class, there are many levels of knowledge to learn! Ie., Anatomy, cognitive functions, the tests that test it, and finally relating it to the disorders. Predicitve/ecological ability, how well the NPA predicts future behaviour or behavioural outcomes? One of what of the questions that arise in clinical neuropsychology today... Can we assume something about someone based on how they score on these tests? How do these tests lack this type of validity? What well focus on in this class: - refining tests: not everything comes from the brain in neuropsychology - integration of computerized assessments: we learn that were not able to do a NPA with people in front of us. Some of these patients cannot endure this time or are in remote locations - acquisition of normative data that are lacking: in order to compare performances by the patients, more similar to the patient rather than what is available today (only in the past couple decades did we start to notice that differences in things like culture or education level affect what the data produces...) Next week: basic concepts on what hes already led to! Anything related to the exam, e-mail Sara, anything else, e-mail Eliyas. Under demonstration (in the text), the tests used in the class demonstration will be described... Clinical Neuropsychology - Lecture 2 Tuesday, January 18th, 2011 Chapter 2 - Basic Concepts Chapter 1 and 2 need to be read in their entirety, later chapters will be more specific.
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