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Chapter 1

PSYC31 - Clinical Neuropsychology Ch. 1

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Pare, Dwayne

PSYC31 – Chapter 1: The Practice of Neuropsychological Assessment  Clinical neuropsychology is an applied science concerned with the behavioral expression of brain dysfunction  In the 19 century, the idea of controlled observations became generally accepted, providing the conceptual tool with which the first generation of neuroscientists laid out the basic schema of brain-behavior relationships that hold today  War damaged brains gave the chief impetus to the development of clinical neuropsychology  Screening and diagnosis of brain injured and behaviorally disturbed servicemen during WWI and for their rehabilitation created demands for neuropsychology programs  Psychology contributed the two other domains of knowledge and skill that are integral to the scientific discipline and clinical practices of neuropsychology today  Binet initially developed tests to capture the concept of intelligence  Mental measurement specialists produced examination techniques to screen recruits for military and to assist in educational evaluations o Ex. Raven’s Progressive Matrices, Wechsler Intelligence Scales, Wide Range Achievement Tests  Education testing has been the source of reliable measurement techniques and statistical tools for test standardization and the development of normative data, analysis of research findings, and validation studies  Psychology’s other critical contribution to neuropsychological assessment comes primarily from experimental studies of cognitive functions in both humans and animals  Human studies of cognition mainly dealt with normal subjects  Animal studies and clinical reports of brain injured persons generated much of what was known about the alterations and limitations of specific cognitive functions  Functional neuroimaging gives psychological constructs the neurological bases supporting analysis and comprehension of the always unique and often anomalous multifaceted behavioral presentations of brain injured patients  Psychologists, psychiatrists, and counselors as for neuropsychological assistance in identifying those candidates for their services who may have underlying neurological disorders  Neurologists and neurosurgeons request behavioral evaluations to aid in diagnosis and to document the course of brain disorders or the effects of the treatment  Rehabilitation specialists request neuropsychological assessments to assist in rehabilitation planning and management of neurological condition  Child neuropsychology has developed with advances in the study of mental retardation, neurodevelopmental disorders, and children’s behavior problems  Adults whose cognitive and behavioral problems stem from developmental disorders or childhood onset conditions may also need neuropsychological attention  Neuropsychology has been evolving naturally: assessment tends to play a predominant role , treatment techniques develop as diagnostic categories and etiological relationships are defined and clarified, nature of patients’ disorders become better understood Examination Purposes  Any of six different purposes may prompt a neuropsychological examination o Diagnosis o Patient care (management and planning) o Treatment 1: identifying treatment needs o Treatment 2: evaluating treatment efficacy o Research (theoretical and applied) o Forensic questions  Many assessments serve 2 or more purposes, requiring the examiner to integrate the strategies in order to gain the needed info about the patient in the most focused and succinct manner possible 1. Diagnosis  Neuropsychological assessment can be useful for discriminating between psychiatric and neurological symptoms, identifying a possible neurological disorder in a non-psychiatric patient, helping to distinguish between different neurological conditions and providing behavioral data for localizing the site of a lesion  Neuropsychological assessment as a diagnostic tool has diminished while patient care and treatment have grown (this shift is due in part to the development highly sensitive and reliable noninvasive neurodiagnostic techniques)  Despite the general similarities in the pattern of brain function sites, these patterns will differ more or less between people  Cognitive assessment can document mental abilities that are inconsistent with anatomic findings such as the 101-year old nun whose test scores were high but autopsy showed classic lesions of Alzheimer’s disease  Neuropsychological assessment can aid in prodromal or early detection and prediction of dementing disorders or outcome  Pharmacologic research may engage neuropsychological assessment to assist in predicting responders and best psychopharmacological treatments in mood disorders  In patients with interactable epilepsy, neuropsychological evaluations are critical for identifying candidates for surgery as well as for implementing postsurgical programs  Screening is another aspect of diagnosis  Screening was a rather crudely conceived affair  Little attention was paid to either base rate issues or the prevalence of conditions in which psychiatric and neurologic contributions were mixed and interactive  In the last decade, screening tests have been developed for identifying neurocognitive and neurobehavioral changes in TBI patients 2. Patient Care and Planning  Many patients are referred for detailed info about their cognitive status, behavioral alterations, and personality characteristics  Rational planning usually depends on an understanding of patients’ capabilities and limitations, the kinds of psychological change they are undergoing and the impact of these changes on their experiences of themselves and on their behavior  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  Neuropsychological assessment plays a key role in monitoring cognitive and neurobehavioral status following a TBI  Data from successive neuropsychological examinations repeated at regular intervals can provide reliable indications of whether the underlying neurological condition is changing and if so, how rapidly and in what ways  Repeated testing may also be used to measure the effects of surgical procedures, medical treatments, or retraining  Brain impaired patients must have factual info about their functioning to understand themselves and to set realistic goals  Neurological impairment may diminish a patient’s capacity for empathy especially when damage occurs in prefrontal regions  Distrust of their experiences, particularly their memory and perceptions, is a problem shared by many brain damaged persons  This self-distrust seems to reflect feelings of strangeness and confusion accompanying previously familiar habits, thoughts, and sensations that are now experienced differently, and from newly acquired tendencies to make errors  The self-doubt of the brain injured person referred to as perplexity, is usually distinguishable from neurotic self-doubts about life goals, values, principles etc. 3. Treatment 1: Treatment Planning and Remediation  Today, much more of the work of neuropsychologists is involved in treatment or research on treatment  Of particular neuropsychological importance is the ongoing developments of treatment programs for soldiers sustaining brain injuries in the Gulf, Iraq, and Afghanistan wars  Assessments include both delineation of problems areas and evaluation of the patient’s strengths and potential for rehabilitation  Repeated assessments will be required to adapt programs and goals to the patient’s changing needs and competencies  Since rehabilitation treatment and
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