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Outline

1. Neuropsychological Assessmenta. Goals of neuropsychological assessmentb. Psychometric approach – advantagesc. Psychometric approach – interpretation

2. IQ and Neuropsychological Testing3. Malingering

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Outline

4. Neuropsychological Test Batteriesa. Halstead-Reitan5. Functions of interest to neuropsychologists

a. Lateralityb. Visual Perceptionc. Languaged. Memorye. Attention & Executive Control

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1. Neuropsychological Assessment

Goals • Diagnosis• What happened that

damaged the patient’s brain?

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1. Neuropsychological Assessment

• Goals • Description• What went wrong

cognitively, emotionally, or behaviorally as a result?

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1. Neuropsychological Assessment

• Goals • Tracking changes• Observe changes in

patient’s performance over time, to monitor healing/worsening and effects of treatment

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1. Neuropsychological Assessment – advantages

• Standardized:• Repeatable instructions,

presentation, and tasks• Norms

• Intensive:• Multiple measures

within and among wide range of domains

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1. Neuropsychological Assessment – advantages

• Sensitive• Valid indicators of skills,

capable of detecting abilities and deficits

• Scaled• Hierarchical items• Start/stop rules

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1. Neuropsychological Assessment – advantages

• Precise• Allows reliable, exacting

quantification of relative abilities

• Allows comparison within/over time

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1. Neuropsychological Assessment

• Interpretation • Quantitative observations:• Many tests give

standardized scale scores (like Wechsler tests) based on norms

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1. Neuropsychological Assessment

• Interpretation • Actuarial results (e.g., Boston Aphasia Battery) – profile of subtest scores indicates nature of disorder

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1. Neuropsychological Assessment

• Interpretation • Cut-off scores used to make decisions

• How are cut-offs set? Norm-referenced? Criterion-referenced?

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1. Neuropsychological Assessment

• Interpretation • Neuropsychologists also make up tests as needed – these typically are not standardized, so interpretation may be problematic.

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1. Neuropsychological Assessment

• Interpretation • Example: line-crossing task used to detect “neglect” following right-hemisphere brain damage

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1. Neuropsychological Assessment

• What do we know about the line-crossing test? What cognitive operations are involved in test performance?

• Why do neglect patients fail at this test?

• Is this test valid? Reliable?

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2. IQ and neuropsychological testing

• Estimating pre-morbid IQ may be necessary to determine whether there is actual loss of function or capacity.

• Often difficult to use a regular IQ test with patients

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2. IQ and neuropsychological testing

• Estimating pre-morbid IQ – Clinical approaches

• Education• Vocabulary• Occupation, farm size• Functional capacities

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2. IQ and neuropsychological testing

• Actuarial & psychometric approaches

• Demographic formulas• Reading level• Subtest pattern

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3. Malingering

• Faking a disorder or deficit.

• Important for legal and financial reasons – people sometimes fake a deficit in order to collect insurance payments, or to fraudulently obtain narcotics

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3. Malingering

• Tests to catch malingering usually based on fact malingerers don’t know what real deficits look like – they often show too much loss of function.

• Munchausen Syndrome – psychopathology involves faking illness, but not for money or drugs

• Rarely treated successfully

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4. Neuropsychological test batteries

• Test batteries – large sets of tests

• Wide variety of tests to tap many different skills and abilities

• Developed before the era of brain scanning, in part to help locate site of brain damage

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To use test batteries or not?

• On the plus side:• Many batteries have known psychometric

properties (e.g., reliability, validity).• Use of standardized procedure permits

comparison of one patient with others, even if the others are tested by different clinicians.

• Tests cover a wide range of cognitive functions and behaviors

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To use test batteries or not?

• On the minus side:• Test-centered rather than patient-centered

• Time-consuming• Patient may fail a test for many different reasons

• Batteries are developed for general purposes – may lack flexibility to assess any given patient’s idiosyncratic deficits.

• May reduce clinician’s potentially useful curiosity, lead to “cookie-cutter reports.”

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4a. HRNTB

• Ward Halstead • Ph.D. psychologist, taught in U Chicago Medical

School• Through 1940s, devised and tried out many tests

for use with brain-damaged patients• With his student Ralph Reitan, settled on a battery

of tests that allowed comprehensive evaluation of BD patients

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Reitan’s four-fold approach

• Inferential decision-making using the HRNTB based on:

• Level of performance• Pattern of performance• Specific behavioral

deficits• Comparison of two

sides of the body (right-left comparisons)

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Reitan’s four-fold approach

• Level of performance • Comparison of individual with normative groups of impaired and non-impaired persons

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Reitan’s four-fold approach

• Pattern of Performance • Examination of intra-test performance and subtest scores

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Reitan’s four-fold approach

• Specific Behavioral Deficits

• Sensitivity to deviant or deficient performance which, of itself, points to impairment

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Reitan’s four-fold approach

• Comparison of Two Sides of the Body

• Looking for discrepancies in test performance which may reveal weakness or lateralized impairment

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4a. HRNTB

• Category test• Tests abstraction and

reasoning

• Tactual performance test• Manual dexterity, spatial

memory, tactile discrimination

• Seashore rhythm test & Speech-sounds perception test• Attention,

concentration, auditory discrimination

• Finger tapping test• Motor speed and

manual dexterity

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4a. HRNTB

• Trail making (see below)

• Reitan-Indiana Aphasia Screening Examination

• Reitan-Klove Sensory Perceptual Examination• Version of standard

neurological screening test for sensory processes

• Strength of Grip Test• Uses hand dynamometer

• Lateral Dominance Examination

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Functions of interest to neuropsychologists

a. Lateralityb. Visual Perceptionc. Languaged. Memorye. Attention & Executive Control

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5a. Laterality

• Compares functions of the L and R hemispheres of the cortex

• Especially important if neurosurgery is planned: where are language functions?

• Language functions are in left hemisphere in most people, bilateral in some

• Annett Handedness Questionnaire

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Annett Handedness Questionnaire

Please indicate which hand you habitually use for each of the following: (R, L or E)

1. Writing2. Throwing a ball3. Holding a racquet 4. Striking a match5. Cut with scissors6. Threading a needle7. At top of broom8. At top of shovel9. To deal cards10. To hammer a nail11. To hold a toothbrush12. To unscrew a lid

There are several ways to score this test

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5b. Visual Perception

• Visual field deficits • Informal assessment by clinician

• More precise assessment requires special optometry equipment.

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5b. Visual Perception

• Agnosia – inability to recognize familiar objects visually.

• To test – ask patient to name various objects

• Meaning of objects has not been lost –it’s a deficit of visual recognition.

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Visual agnosias

• visual object agnosia – inability to identify common visual objects

• prosopagnosia – inability to recognize familiar faces

• color agnosia – inability to discriminate between colors and to name colors

• simultanagnosia – visual perception of simultaneously presented objects is impaired

Figure/ground discrimination – separate figure from background

The embedded figures test – task is to find all the objects in this figure.

The objects in the embedded figures test stimulus

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Visual Memory

• Rey-Osterrieth figure• complicated, abstract

figure (next slide)• patient looks at it briefly

then asked to reproduce the figure from memory

• scoring is quite complex• assesses visual memory,

visual construction skill

The Rey-Osterrieth Complex Figure (Osterrieth, 1946)

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5c. Language

• A very important function for humans, typically mediated by left hemisphere

• Expressive and receptive language can be independently lost or spared

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5c. Language

• Batteries include Boston Diagnostic Aphasia Examination and Western Aphasia Battery (developed at UWO School of Medicine)

• Task-specific tests used with patients having comparatively isolated dysfunctions

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Boston Diagnostic Aphasia Examination

• Oral Expression – word repetition, body part naming, visual confrontation naming

• Writing

• Auditory comprehension: Body part identification

• Understanding written language: Word picture matching.

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Task-specific tests

• Graded Naming Test or Boston Naming Test - both assess ability to name objects.

• Token Test - detects non-obvious loss of receptive language

• Pyramid & Palm Trees Test - tests the understanding of words

Graded Naming Test examples – test has 30 of these, presented in order of increasing difficulty Boston Naming Test examples

Pyramid

Palm Tree

Fir Tree

3 Picture Version 3 Word Version

Pyramid and Palm Trees Test – which one of the two lower items goes with the upper item?

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5d. Memory

• Amnesia is loss of episodic (personal) memory, which may include knowledge of public people/events

• Two distinct kinds of amnesia:• Retrograde• Anterograde

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5d. Memory

• Retrograde • loss of memory for

events from patient’s past

• patient asked to retrieve old events

• Anterograde• loss of ability to store

new memories.• patient exposed to new

information, then memory for that information tested

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Retrograde amnesia

• Boston Remote Memory test

• 2 types of questions• Easy vs. hard

• 2 types of material• Famous faces (hints

given if needed)• Events – asked to recall

information about them

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Anterograde amnesia

• Warrington’s Recognition Memory Test• 50 faces and 50 words

presented separately• 2AFC test administered

immediately after learning phase

• Severely impaired patients may perform at chance.

• Then, it’s hard to tell what’s wrong with their memory

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Anterograde amnesia

• Wechsler Memory Scale III• Separate short-term and

long-term retention scores

• Tries to differentiate between verbal and non-verbal elements of memory

• Includes recall and recognition tests

• 2+ hours to administer

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5e. Attention & Executive Control

• Spatial attention: Line bisection, cancellation tasks

• Sustained attention / vigilance: Continuous performance test (CPT)

• Focused attention: Dichotic listening / visual search

• Divided attention: Trail making, task combinations

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Trails A

8

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3

1

95

6

107

Trails B

A

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B

1

CD

E

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Trails A and Trails B – from Halstead-Reitan test battery

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5. Attention & Executive Control

• Executive functions• Assess higher cortical

functions such as planning, response inhibition, controlled functions (e.g., new task, or new environment).

• Wisconsin Card Sort Task used frequently

Sort according to unspoken rule; examiner changes rule – can patient adapt to new rule?

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