Les 1 10/09/2025
Psychologists still find it striking that we find so many cognitive impairments in psychiatry. In
neurological disorders it is more expected to have impairments, but apparently, to many
psychologists it is unexpected to find these in psychiatry.
Historical perspective on psychiatry
Psychiatry is a quite newly evolved discipline. Before 1800 patients lived in institutions, locked away
to protect society. There were no doctors or treatments involved. The French revolution is sort of a
turning point in psychiatry (1790s). The French psychiatrist Pinel started moral treatment
(psychotherapy, treating people like humans, talking to them, etc.). In 1860s in Germany, people
started studying the link between brain and behaviour (this is the first time that psychiatry was
viewed as a medical discipline). This was an important development. Later, in 1890s, Kraepelin was
the first to categorize and classify mental disorders. Before this, individuals were seen as separate
cases with problematic behaviour. This was a very early version of what we now know as the
DSM/ICD handbooks. He focused mainly on biological factors underlying psychiatric disorders, not so
much on behaviour.
While Kraepelin had a biological perspective, there was a countermovement regarding the subjective
experiences (saying it is not only biology, but there are also mental processes at play). This started in
1880s with Janet, he did hypnosis/catharsis. In 1890s came Freud’s psychoanalysis. These people
were very important in the current development of psychotherapy (these were the first/very early
forms of psychotherapy). After that (1900s) a strong biological view arose again, the biological
psychiatry (ECT, lobotomy). In the 1940s psychopharmaca came into play (chloorpromazine: first
antipsychotic drugs): ‘proof for brain dysfunction’. Everything they did at the time seemed good,
however, looking back we see the downsides (e.g., about the lobotomy or the side-effects of the
drugs). But of course, it is easy to say that now. In the 1950s there was the introduction of the first
DSM which was a very important development in psychiatry. In the 1960s the neuropsychology in
psychiatry arose (e.g., schizophrenia).
Modern psychiatry
It is a mixture between brain and environment. Genes only explain so much, environmental factors
are also important. A lot of psychiatric disorders have exposure to stress in common (environmental).
In the past, they mainly focused on reducing the symptoms (symptomatic treatment). However, this is
not the only important thing. People with psychiatric disorders also often get isolated from society,
etc. So, nowadays the aim of recovery is beyond symptomatic remission. Reducing symptoms is not
the only important factor. People often lose their job, connection with friends, etc. they also might
have difficulties living a meaningful life. This is all important to focus on and to have interventions for.
Symptomatic recovery, functional recovery and personal recovery are all addressed in treatment now.
- There are psychosocial and pharmacological treatments in modern psychiatry.
- The DSM-5 (2013) is the leading handbook in Europe, however, there has been a lot of
criticism on the DSM-5 (only summing up symptoms, etc.). It is a categorisation of disorders.
- The NIMH RDoC is not classifying psychiatric disorders, but it describes specific symptoms
(behavioural and cognitive problems at different levels). Goal: understanding the nature of
mental health and illness in terms of varying degrees of dysfunction in fundamental
psychological/biological systems. It is not used to replace the DSM, but in specific studies
where you want to focus on symptom dimensions regardless of classification.
Definitions
- Psychiatry: medical specialty concerned with the diagnosis and treatment of mental illness
, - Neurology: medical speciality concerned with the diagnosis and treatment of disorders of the
nervous system (brain, spinal cord and nerves)
- Neuropsychology: psychological specialty concerned with the relationship between
behaviour, emotion and cognition on the one hand and brain function on the other
The first two are medical disciplines while neuropsychology is not, it is s psychological discipline. The
medical disciplines are focused on treatment, while neuropsychology is in the basics a more scientific
approach. She also adds to the definition of neuropsychology that neuropsychologists understand the
cognitive factors underlying behaviour.
Another way of looking at the difference between neurology and psychiatry is through different
disorders in a corelation matrix. The darker the colour, the stronger the correlation is. We see genetic
correlations (genes associated with certain disorders) between neurological phenotypes. We see that
there are associations between some neurological phenotypes but there is not much overlap.
However, if we look at the same picture for psychiatry, there is much more overlap. The underlying
genes associated with specific disorders overlap quite a lot. So, it is not easy to make sharp
boundaries between psychiatric disorders because there is overlap in underlying genes and overt
behaviour. While there are specific disorders in neurology with specific onset, symptoms, genes, etc.,
the boundaries are much less clear in psychiatry between types of disorders.
Traditional neuropsychology
- Assessment traditionally focusses on determining specific changes in mental processes after
discrete brain lesions. So, the main aim was to determine the focus of lesions and relating
brain areas to specific cognitive processes/functions.
- This helped to determine the locus of the lesion
- Knowledge on the role of brain areas in mental processes
- Focus on neurological patients
How we see ourselves (as neuropsychologists):
- We generate hypothesis on underlying mechanisms/symptoms. E.g., if you have a list of
symptoms (hallucinations, delusions, etc.), what we do as neuropsychologists is linking these
symptoms to specific cognitive processes. This is an example of how you can link many
psychiatric symptoms to cognitive functions (don’t have to remember the list).
- We want to understand the role of cognitive processes in the etiology and the presentation of
psychiatric disorders (biomedical model).
- Understanding of the clinical, behavioural, and phenomenological correlates of
“neuropsychological impairments”.
- Doing individual neuropsychological assessments (profile of strengths and weaknesses)
How psychiatrist see us (neuropsychologists):
- Useful but underutilized resource
- Establishing deterioration in cognitive functioning
- Making differential diagnosis (we can do this in neurology with neuropsychological
assessment; it is not possible to make a full differential diagnosis in psychiatry based on
neuropsychological assessment alone because there is not a specific cognitive
profile/cognitive impairment for psychiatric disorders such as schizophrenia, OCD, etc.).
- Facilitating improved outcomes
- Psychiatrists need to recognise cognitive impairments and to understand common
neuropsychological tests
Assessment questions in psychiatry
- What is the DSM 5 label? (can you make a differential diagnosis?)
, - Will this person be able to go back to school/work?
- Are there cognitive limitations that should be taken into account in the treatment of this
person?
- Can you evaluate the effect of pharmacological interventions on cognitive functioning?
- Are the cognitive impairments due to ADHD or drug use?
- Please assess cognitive functions!!
Traditional interpretation errors
- Neuropsychological tests measure specific functions, and poor performance on a single test
indicates a specific neuropsychological deficit people can sometimes assume this, e.g., if a
patient performs bad on one test of EF, what can we conclude from this? You cannot
conclude anything from one test alone. It could have been that the person also has attention
problems which impaired performance. So, you can formulate hypothesis, but you must do
more tests to make any conclusions.
- Abnormal neuropsychological test performance indicates specific regional brain dysfunction
this is true for very few cases, in psychiatry this is hardly the case.
- “Hypoactivity” during functional imaging procedures with cognitive activation tasks suggests
regional brain dysfunction (in a lot of patients with depression, ADHD, schizophrenia we see
that their frontal lobe is functioning less, this doesn’t mean that there is a structural
impairment, but it does reflect that they are not able to mobilize the energy needed for test
performance. So, it means that they are not able to generate/use the energy needed to
perform in the task).
- Directly linking brain areas and disorders/personality/sexual orientation: neophrenology
- Making a psychiatric diagnosis based on neuroimaging studies
- Reductionism: psychological conditions are brain disorders associated with a state of
chemical imbalance
- Assuming an association between functional impairments and neuropsychological
impairment is disorder-specific
- Assuming neuropsychological dysfunction causes such functional impairments
Therapy
- Cognitive remediation (recommended to combine this with other treatment so that people
can practice their newly acquired/improved cognitive skills to apply in practice, this can
facilitate better outcomes; another new finding is to combine it with physical exercise).
- Neuropsychological test data can be used to develop treatment strategies tailored for an
individual’s specific cognitive strengths and deficits (‘rate limiting factors’)
, Les 2 17/09/2025
Schizophrenia – psychotic disorders
The term schizophrenia is a bit outdated because we consider it now as psychotic disorders or
schizophrenia disorders as a spectrum. With schizophrenia at the more severe end with impairments
in social and daily functioning but there are also more mild psychotic disorders. The more severe
psychotic disorders are, the more cognitive impairments we find.
The DSM-5 classification of schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a 1-
month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions (opinions, thoughts that you have that are not shared by other people;
e.g., paranoid delusions). Delusions can be pleasant (think you are special, this is
often overcompensation for a very low self-esteem), not pleasant, etc. they can be
triggered by hallucinations or be combined with hallucinations
2. Hallucinations (can be pleasant or not; these perceptual distortions or mild
hallucinations are also common happen in the ‘normal’ population; the same holds
for delusional thinking. So, we should not necessarily treat them unless they or their
environment is suffering)
3. Disorganized speech (e.g., frequent derailment or incoherence; no executive control
over your talking; you make loose associations; there is no real goal in your speech)
4. Grossly disorganized or catatonic behaviour (repetitive, stereotypical or catatonic
behavior)
5. Negative symptoms (i.e., diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in
one or more major areas, such as work, interpersonal relations, or self-care, is markedly
below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or
occupational functioning)
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) and may include periods
of prodromal or residual symptoms. During these prodromal or residual periods, the signs of
the disturbance may be manifested by only negative symptoms or by two or more symptoms
listed in criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual
experiences)
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been
ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration of the
active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition
F. If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if prominent delusions or
hallucinations, in addition to the other required symptoms of schizophrenia, are also present
for at least 1 month (or less if successfully treated)
Delusions and hallucinations together are called the positive symptoms (because they add to normal
behaviour). For negative symptoms, someone misses something that is present in ‘normal’
individuals, i.e., diminished emotional expression, avolition or apathic behaviour; they do experience
emotions the same way, but it is most likely just a lack of expression instead of an emptiness. So, even
Psychologists still find it striking that we find so many cognitive impairments in psychiatry. In
neurological disorders it is more expected to have impairments, but apparently, to many
psychologists it is unexpected to find these in psychiatry.
Historical perspective on psychiatry
Psychiatry is a quite newly evolved discipline. Before 1800 patients lived in institutions, locked away
to protect society. There were no doctors or treatments involved. The French revolution is sort of a
turning point in psychiatry (1790s). The French psychiatrist Pinel started moral treatment
(psychotherapy, treating people like humans, talking to them, etc.). In 1860s in Germany, people
started studying the link between brain and behaviour (this is the first time that psychiatry was
viewed as a medical discipline). This was an important development. Later, in 1890s, Kraepelin was
the first to categorize and classify mental disorders. Before this, individuals were seen as separate
cases with problematic behaviour. This was a very early version of what we now know as the
DSM/ICD handbooks. He focused mainly on biological factors underlying psychiatric disorders, not so
much on behaviour.
While Kraepelin had a biological perspective, there was a countermovement regarding the subjective
experiences (saying it is not only biology, but there are also mental processes at play). This started in
1880s with Janet, he did hypnosis/catharsis. In 1890s came Freud’s psychoanalysis. These people
were very important in the current development of psychotherapy (these were the first/very early
forms of psychotherapy). After that (1900s) a strong biological view arose again, the biological
psychiatry (ECT, lobotomy). In the 1940s psychopharmaca came into play (chloorpromazine: first
antipsychotic drugs): ‘proof for brain dysfunction’. Everything they did at the time seemed good,
however, looking back we see the downsides (e.g., about the lobotomy or the side-effects of the
drugs). But of course, it is easy to say that now. In the 1950s there was the introduction of the first
DSM which was a very important development in psychiatry. In the 1960s the neuropsychology in
psychiatry arose (e.g., schizophrenia).
Modern psychiatry
It is a mixture between brain and environment. Genes only explain so much, environmental factors
are also important. A lot of psychiatric disorders have exposure to stress in common (environmental).
In the past, they mainly focused on reducing the symptoms (symptomatic treatment). However, this is
not the only important thing. People with psychiatric disorders also often get isolated from society,
etc. So, nowadays the aim of recovery is beyond symptomatic remission. Reducing symptoms is not
the only important factor. People often lose their job, connection with friends, etc. they also might
have difficulties living a meaningful life. This is all important to focus on and to have interventions for.
Symptomatic recovery, functional recovery and personal recovery are all addressed in treatment now.
- There are psychosocial and pharmacological treatments in modern psychiatry.
- The DSM-5 (2013) is the leading handbook in Europe, however, there has been a lot of
criticism on the DSM-5 (only summing up symptoms, etc.). It is a categorisation of disorders.
- The NIMH RDoC is not classifying psychiatric disorders, but it describes specific symptoms
(behavioural and cognitive problems at different levels). Goal: understanding the nature of
mental health and illness in terms of varying degrees of dysfunction in fundamental
psychological/biological systems. It is not used to replace the DSM, but in specific studies
where you want to focus on symptom dimensions regardless of classification.
Definitions
- Psychiatry: medical specialty concerned with the diagnosis and treatment of mental illness
, - Neurology: medical speciality concerned with the diagnosis and treatment of disorders of the
nervous system (brain, spinal cord and nerves)
- Neuropsychology: psychological specialty concerned with the relationship between
behaviour, emotion and cognition on the one hand and brain function on the other
The first two are medical disciplines while neuropsychology is not, it is s psychological discipline. The
medical disciplines are focused on treatment, while neuropsychology is in the basics a more scientific
approach. She also adds to the definition of neuropsychology that neuropsychologists understand the
cognitive factors underlying behaviour.
Another way of looking at the difference between neurology and psychiatry is through different
disorders in a corelation matrix. The darker the colour, the stronger the correlation is. We see genetic
correlations (genes associated with certain disorders) between neurological phenotypes. We see that
there are associations between some neurological phenotypes but there is not much overlap.
However, if we look at the same picture for psychiatry, there is much more overlap. The underlying
genes associated with specific disorders overlap quite a lot. So, it is not easy to make sharp
boundaries between psychiatric disorders because there is overlap in underlying genes and overt
behaviour. While there are specific disorders in neurology with specific onset, symptoms, genes, etc.,
the boundaries are much less clear in psychiatry between types of disorders.
Traditional neuropsychology
- Assessment traditionally focusses on determining specific changes in mental processes after
discrete brain lesions. So, the main aim was to determine the focus of lesions and relating
brain areas to specific cognitive processes/functions.
- This helped to determine the locus of the lesion
- Knowledge on the role of brain areas in mental processes
- Focus on neurological patients
How we see ourselves (as neuropsychologists):
- We generate hypothesis on underlying mechanisms/symptoms. E.g., if you have a list of
symptoms (hallucinations, delusions, etc.), what we do as neuropsychologists is linking these
symptoms to specific cognitive processes. This is an example of how you can link many
psychiatric symptoms to cognitive functions (don’t have to remember the list).
- We want to understand the role of cognitive processes in the etiology and the presentation of
psychiatric disorders (biomedical model).
- Understanding of the clinical, behavioural, and phenomenological correlates of
“neuropsychological impairments”.
- Doing individual neuropsychological assessments (profile of strengths and weaknesses)
How psychiatrist see us (neuropsychologists):
- Useful but underutilized resource
- Establishing deterioration in cognitive functioning
- Making differential diagnosis (we can do this in neurology with neuropsychological
assessment; it is not possible to make a full differential diagnosis in psychiatry based on
neuropsychological assessment alone because there is not a specific cognitive
profile/cognitive impairment for psychiatric disorders such as schizophrenia, OCD, etc.).
- Facilitating improved outcomes
- Psychiatrists need to recognise cognitive impairments and to understand common
neuropsychological tests
Assessment questions in psychiatry
- What is the DSM 5 label? (can you make a differential diagnosis?)
, - Will this person be able to go back to school/work?
- Are there cognitive limitations that should be taken into account in the treatment of this
person?
- Can you evaluate the effect of pharmacological interventions on cognitive functioning?
- Are the cognitive impairments due to ADHD or drug use?
- Please assess cognitive functions!!
Traditional interpretation errors
- Neuropsychological tests measure specific functions, and poor performance on a single test
indicates a specific neuropsychological deficit people can sometimes assume this, e.g., if a
patient performs bad on one test of EF, what can we conclude from this? You cannot
conclude anything from one test alone. It could have been that the person also has attention
problems which impaired performance. So, you can formulate hypothesis, but you must do
more tests to make any conclusions.
- Abnormal neuropsychological test performance indicates specific regional brain dysfunction
this is true for very few cases, in psychiatry this is hardly the case.
- “Hypoactivity” during functional imaging procedures with cognitive activation tasks suggests
regional brain dysfunction (in a lot of patients with depression, ADHD, schizophrenia we see
that their frontal lobe is functioning less, this doesn’t mean that there is a structural
impairment, but it does reflect that they are not able to mobilize the energy needed for test
performance. So, it means that they are not able to generate/use the energy needed to
perform in the task).
- Directly linking brain areas and disorders/personality/sexual orientation: neophrenology
- Making a psychiatric diagnosis based on neuroimaging studies
- Reductionism: psychological conditions are brain disorders associated with a state of
chemical imbalance
- Assuming an association between functional impairments and neuropsychological
impairment is disorder-specific
- Assuming neuropsychological dysfunction causes such functional impairments
Therapy
- Cognitive remediation (recommended to combine this with other treatment so that people
can practice their newly acquired/improved cognitive skills to apply in practice, this can
facilitate better outcomes; another new finding is to combine it with physical exercise).
- Neuropsychological test data can be used to develop treatment strategies tailored for an
individual’s specific cognitive strengths and deficits (‘rate limiting factors’)
, Les 2 17/09/2025
Schizophrenia – psychotic disorders
The term schizophrenia is a bit outdated because we consider it now as psychotic disorders or
schizophrenia disorders as a spectrum. With schizophrenia at the more severe end with impairments
in social and daily functioning but there are also more mild psychotic disorders. The more severe
psychotic disorders are, the more cognitive impairments we find.
The DSM-5 classification of schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a 1-
month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions (opinions, thoughts that you have that are not shared by other people;
e.g., paranoid delusions). Delusions can be pleasant (think you are special, this is
often overcompensation for a very low self-esteem), not pleasant, etc. they can be
triggered by hallucinations or be combined with hallucinations
2. Hallucinations (can be pleasant or not; these perceptual distortions or mild
hallucinations are also common happen in the ‘normal’ population; the same holds
for delusional thinking. So, we should not necessarily treat them unless they or their
environment is suffering)
3. Disorganized speech (e.g., frequent derailment or incoherence; no executive control
over your talking; you make loose associations; there is no real goal in your speech)
4. Grossly disorganized or catatonic behaviour (repetitive, stereotypical or catatonic
behavior)
5. Negative symptoms (i.e., diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in
one or more major areas, such as work, interpersonal relations, or self-care, is markedly
below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or
occupational functioning)
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) and may include periods
of prodromal or residual symptoms. During these prodromal or residual periods, the signs of
the disturbance may be manifested by only negative symptoms or by two or more symptoms
listed in criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual
experiences)
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been
ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration of the
active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition
F. If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if prominent delusions or
hallucinations, in addition to the other required symptoms of schizophrenia, are also present
for at least 1 month (or less if successfully treated)
Delusions and hallucinations together are called the positive symptoms (because they add to normal
behaviour). For negative symptoms, someone misses something that is present in ‘normal’
individuals, i.e., diminished emotional expression, avolition or apathic behaviour; they do experience
emotions the same way, but it is most likely just a lack of expression instead of an emptiness. So, even
