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Chapter 5

PSYC31H3 Chapter Notes - Chapter 5: Statistical Hypothesis Testing, Sleep Deprivation, Free Recall

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Konstantine Zakzanis

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Clinical Neuropsychology Readings
January 14th 2016
Chapter Five:
Examination tailored to the patient’s needs, abilities, and limitations, and to special examination requirements.
Neuropsychological examinations may be conducted for any number of purposes:
o To explain behavior
o To aid in diagnosis
o To help with management, care, and planning
o To evaluate the effectiveness of a treatment technique
o To provide information for a legal matter
o To do research
Examination Questions:
o The purpose(s) of the examination should determine its overall thrust and the general questions that need
to be asked.
o Examination questions fall into one of two categories:
Diagnostic questions: concern the nature of the patient’s symptoms and complaints in terms of
their etiology and prognosis.
I.e., ask whether the patient has a neuropsychologically relevant condition, and if so
These questions are typically asked when patients are referred for a neuropsychological
evaluation following the emergence of a cognitive or behavioral problem without an
established etiology.
Differential diagnosis: questions concerning the nature of the patient’s
Can sometimes hinge on data from the personal history, the nature of
the onset of the condition, and the circumstances surrounding its
Depend on syndrome analysis.
The diagnostic process involves the successive elimination of alternative possibilities, or
Descriptive questions: inquire into the characteristics of the patient’s condition.
I.e., ask how the patient’s problem is expressed.
Serial studies question whether the condition has changed from a previous examination.
Questions about the patient’s competencies may be at least as important as those about
the patient’s deficits.
Questions also may arise about the patient’s rehabilitation potential and the best
approach to use.
o Baseline study: provides the first data set against which the findings of later examinations will be
Repeated assessments give information about the rate and extent of improvement or
deterioration and about relative rates of change between functions.
Examination Foundations:
o Evidence-based practice: the integration of clinical expertise with the best research evidence and patient
o Examiner must “know what they don’t know” and refer them to someone who does.
o In neuropsychological assessment, few if any single bits of information are meaningful in themselves.
o Context for interpreting the examination findings may come from any of five aspects of the patient’s
Social history
Information about the patient’s educational and work experiences may be the best
source of data about the patient’s original cognitive potential.
Knowing the socioeconomic status of the patient’s family of origin as well as current
socioeconomic status is often necessary for interpreting cognitive test scores.
Present life circumstances
The examiner should go beyond factual questions about occupation, income and
indebtedness, family statistics, and leisure activities to find out the patient’s views and
feelings about these issues.
Medical history and current medical status
Discrepancies between patients’ reports of health history and medical records may give a
clue to the nature of their complaints or to the presence of a neuropsychological
Circumstances surrounding the examination
Test performance can be evaluated accurately only in light of the reasons for referral
and the relevance of the examination to the patient.
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The patient’s values and needs will determine the patient’s expectations and response
to the evaluation.
What the patient believes will be gained or lost as a result of the
neuropsychological evaluation.
Cultural background
o Blind analysis: the examiner evaluates a set of test scores without benefit of history, records, or ever
having seen the patient.
May be useful for teaching or reviewing a case.
Inappropriate as a basis for clinical decisions.
Examination Procedure:
o The way patients learn of their referral for neuropsychological assessment can affect how they view the
Sets the stage for such diverse responses as cooperation, anxiety, distrust, and other attitudes
that may modify test performance.
Patient’s questions
o The patient’s questions might not match those of the referral source of the examiner.
o Examiner should educate patient about how the examination may answer the patient’s questions.
o Can also help patient reformulate questions.
When to examine
o Sudden onset conditions (e.g., trauma, stroke)
The first weeks or months following a sudden onset event, a brief examination may be necessary
for several reasons:
To ascertain the patient’s ability to comprehend and follow instructions.
To evaluate mental capacity when the patient may require a guardian.
To determine whether the patient can retain enough new information to begin a
retraining program.
Early on, examiner can identify area(s) of impaired cognition.
o Acute or postacute stages
A full assessment should NOT be undertaken during this period.
Up to the first 6-12 weeks, neuropsychological status can occur so rapidly that
information gained can be obsolete the next.
Fatigue causes cognitive abilities to decline.
o After the postacute stage
When patient’s sensorium has cleared and stamina has been regained (within 3-6 months) an
initial comprehensive exam can take place.
When impairment is more severe, a typical early assessment may have several goals.
E.g., to make an initial projection about the patient’s ultimate levels of impairment and
o Long-term planning
Examinations can be done sometime within 1-2 years after the event.
o Evolving conditions (e.g., degenerative diseases, tumor)
Early in the course of an evolving condition when neurobehavioral problems are first suspected,
the neuropsychological examination can contribute significantly to diagnosis.
Repeated exams may become necessary.
Exams 6-8 months after may prove more definitive.
Neuropsychological examination proceeds in stages:
o Initial planning
Hypotheses to be tested and the techniques used to test them will depend on the examiner’s
understanding and evaluation of the referral questions.
o Preparatory interview
Initial interview and assessment.
Examiner tentatively determines range of functions to be examined.
Fees, referrals, and formal reports are to be discussed with patient at this time.
First 15-20 minutes evaluate patient’s capacity to take tests.
At least seven topics must be covered with competent patients before testing begins if the
examiner wants to be assured of their full cooperation.
a. The purpose of the examination
b. The nature of the examination
c. The use to which examination information will be put (who will receive the report)
d. Confidentiality: control over privacy except when:
i. The exam has been conducted for litigation purposed and all parties to the
dispute may access the findings.
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