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PSYC31H3 (100)
Chapter 1

Chapter One.doc

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University of Toronto Scarborough
Konstantine Zakzanis

Chapter One -clinical neuropsychology is an applied science concerned with the behavioural expression of brain dysfunction -in the 19th century the idea of controlled observations became generally accepted, thus providing the conceptual tool with which the first generation of neuroscientists laid out the basic schema of brain-behaviour relationships that hand today -in the first half of the 20th century, war-damaged brains gave the chief impetus to the development of clinical neuropsychology -the need for screening and diagnosis of brain injured and behaviourally disturbed servicemen during the First World War and for their rehabilitation afterwards created large-scale demands for neuropsychology programs -the Second World War and then the wars in east Asia and the Mideast promoted the development of increasingly sophisticated examination and treatment techniques -educational psychologists, beginning with Binet & Spearman, initially developed tests to capture that elusive concept "intelligence" -mental measurement specialists produced a multitude of examination techniques to screen recruits for the military & to assist in educational evaluations. some of these techniques -such as Raven's progressive matrices, the WIS, & the wide range achievement tests- have been incorporated into the neuropsychological test canon -society's acceptance of educational testing led to a proliferation of large-scale, statistics- dependent testing programs that provide neuropsychology with an understanding of the nature & varieties of mental abilities from a normative perspective -educational testing has also been the source of ever more reliable measurement techniques & statistical tools for test standardization & the development of normative data, analysis of research findings, & validation studies -animal studies & clinical reports of brain injured persons, especially soldiers with localized wounds & stroke patients, generated much of what was known about the alterations & limitations of specific cognitive functions when one part of the brain is missing or compromised - now in the 21st century, dynamic imaging techniques permit viewing functioning brain structures, further refining understanding of the neural foundations of behaviour - functional neuroimaging gives psychological constructs the neurological bases supporting analysis & comprehension of the always unique & often anomalous multifaceted behavioural presentations of brain injured patients -when doing assessments, clinical neuropsychologists typically address a variety of questions of both neurological & psychological import -the practice of neuropsychology calls for flexibility, curiosity, inventiveness, & empathy even in the seemingly most routine situations -each neuropsychological evaluation holds the promise of new insights into the workings of the brain & the excitement of discovery - the rapid evolution of neuropsychological assessment in recent years reflects a growing sensitivity among clinicians generally to the practical problems of identification, assessment, care, & treatment of brain impaired patients - neurologists & neurosurgeons request behavioural evaluations to aid in diagnosis & to document the course of brain disorders or the effects of treatment -rehabilitation specialists request neuropsychological assessments to assist in rehabilitation planning & management of neurological condition -child neuropsychology has developed hand in hand with advances in the study of mental retardation, neurodevelopment disorders including learning disabilities, & children's behaviour problems -adults whose cognitive & behavioural problems stem from development disorders or childhood onset conditions may also need neuropsychological attention - the preponderance of the literature on their problems is in books & articles dealing with development conditions such as ADHD, spina bifida, or hydrocephalus arising from a perinatal incident, or with the residuals of premature birth or childhood meningitis, or the effects of cancer treatment in childhood -neuropsychology has been evolving naturally: assessment tends to play a predominant role while these science are relatively young; treatment techniques develop as diagnostic categories & etiological relationships are defined & clarified, & the nature of the patients' disorders become better understood -treatments planning & evaluation have become not merely commonplace but often necessary considerations for neuropsychologists performing assessments Examination Purposes -any of the six different purposes may prompt a neuropsychological examination: diagnosis; patient care-including questions about management & planning; treatment-1: identifying treatment needs, individualizing treatment programs, & keeping abreast of patients' changing treatment requirements; treatment-2: evaluating treatment efficacy; research, both theoretical & applied; forensic questions are frequently referred to neuropsychologists -many assessments serve two or more purposes, requiring the examiner to integrate the strategies in order to gain the needed information about the patient in the most focused & succinct manner possible 1. Diagnosis -neuropsychological assessment can be useful for discriminating between psychiatric & neuropsychological symptoms, identifying a possible neurological disorder in a nonpsychiatric patient, helping to distinguish between different neurological conditions, & providing behavioural data for localizing the site- or at least the hemisphere side- of a lesion - however, the use of neuropsychological assessment as a diagnostic tool has diminished while its contributions to patient care & treatment & to understanding behavioural phenomena & brain function have grown. This shift is due at least in part to the development of highly sensitive & reliable noninvasive neurodiagnostic techniques -accurate diagnosis & lesion localization are often achieved by means of the neurological examination & laboratory data -still, conditions remaining in which even the most sensitive laboratory analyses may not be diagnostically enlightening, such as toxic encephalopathies, Alzheimer's disease & related cementing processes, or some autoimmune disorders which present with psychiatric symptoms -even when the site & extent of a brain lesion have been shown on imaging, the image will not identify the nature of residual behavioural strengths & the accompanying deficits: for this, neuropsychological assessment is needed -cognitive assessment can document mental abilities that are inconsistent with anatomical findings -Neuropsychological techniques will continue to be an essential part of the neurodiagnostic apparatus -neuropsychological assessment can aid in prodromal or early detection & prediction of cementing disorders or outcome -Huntington's disease -pharmacologic research may engage neuropsychological assessments to assist in predicting responders & best psychopharmacological treatments in mood disorders -in patients with intractable epilepsy, neuropsychological evaluations are critical for identifying candidates for surgery as well as for implementing post surgical programs -screening is another aspect of diagnosis -screening has a place in neuropsychological assessment when used in a more refined manner to identify persons most likely at risk for some specified condition or in need of further diagnostic study, & where brevity is required- whether because of the press of patients who many benefit from neuropsychological assessment or because the patient's condition may preclude a lengthy assessment -in the last decade screening tests have been developed for identifying neurocognitive & neurobehavioral changes in TBI patients 2. Patient care & planning -many patients are referred for detailed information about their cognitive status, behavioural alterations, & personality characteristics- often with questions about their adjustment to their disabilities- so that they & the people responsible for their well-being may know how the neurological condition has affected their behaviour -the neuropsychologist has a responsibility to describe the patient as fully as necessary for intelligent understanding & care -descriptive evaluations may be employed in many ways in the care & treatment of brain injured patients -precise descriptive information about cognitive & emotional status is essential for careful management of many neurological disorders -rationally planning usually depends on an understanding of patients' capabilities & limitations, the kinds of psychological change they are undergoing, & the impact of these changes on their experiences of themselves & on their behaviour -in many cases the neuropsychological examination can answer questions concerning patients' capacity for self-care, reliability in following a therapeutic regimen, not merely the ability to drive a car but to handle traffic emergencies, or appreciation of money & of their financial situation -with all the data of a comprehensive neuropsychological examination taken together- the patient's history, background, & present situation; the qualitative observations; & the quantitative scores- the examiner should have a realistic appreciation of how the patient reacts to deficits & can best compensate for them, & whether & how retraining could be profitably undertaken - data from successive neuropsychological examinations repeated at regular intervals can provide reliable indications of whether the underlying neurological condition is changing, & if so, how rapidly & in what ways -repeated testing may also be used to measure the effects of surgical procedures, medical treatment, or retraining -brain impaired patients must have factual information about their functioning to understand themselves & to set realistic goals, yet their need for this information is often overlooked -neurological impairment may diminish a patient's capacity for empathy, esp
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