Chapter 3 Neuropsychology in clinical practice
3.1 Introduction
A psychologist working in health care is a scientist-practitioner who combines clinical knowledge and
skills with a scientific attitude. The decisions of the neuropsychologist are based on evidence from
scientific research on one hand, and clinical expertise and individual patient needs on the other hand.
Assessment process:
1. Research question
2. Various hypotheses are formulated
3. Data collection (studying the medical file, clinical interview, interview with an informant,
observations, test results, questionnaires)
4. Results are integrated
5. Conclusion
3.2 Areas of expertise
3.2.1 Hospital
Many neuropsychologists work in a hospital setting. A categorical hospital focuses on a specific
patient group. Care in a university hospital is usually closely intertwined with scientific research and
there is a direct collaboration with a university. Within the hospital neuropsychologists collaborate
together with various medical specialists and paramedics. Questions that the neuropsychologist in the
hospital encounters are often focused on diagnostics. By conduction a neuropsychological assessment,
the neuropsychologist maps out the cognitive, emotional and behavioural functioning of a patient and
determines whether the profile fits the (suspected) disorder. In addition, a neuropsychological
assessment is used to describe the consequences of cognitive impairment and its impact on patients’
daily lives. Besides diagnostic questions, the neuropsychologist within a hospital focuses on
treatments mostly of short duration.
3.2.2 Mental health care
Several psychiatric disorders are known to have an effect ton cognitive function, or cognitive
impairments are associated with the disorder itself. Cognitive dysfunctions can also explain specific
neuropsychiatric problems, such as cognitive bias in people with depression or disturbances in
temporal context memory as a mechanism of confabulations. However, it is also possible that after
brain damage, changes in behaviour or personality occur or that psychiatric symptoms develop.
The neuropsychologist within a mental health institution makes use of a neuropsychiatric model,
which examines the relationship between brain, cognition, emotion and behaviour. Both
comprehensive diagnostics and treatment are covered. The diagnostic process is often used to
investigate the cause of the cognitive symptoms reported by patients. Treatment in the mental health
services often last longer than treatments in a hospital.
,3.2.3 Rehabilitation care
In rehabilitation, a multidisciplinary approach is taken, with the patient’s treatment team made up of
the neuropsychologist and other disciplines. Treatment can take place in both inpatient and outpatient
settings. A key theme in rehabilitation is participation: the aim is to enable patients to participate in
activities in society as independently as possible. The neuropsychologist also pays attention to how
patients deal with problems (coping). Coping styles and personality factors play a role in how patients
cope with their condition. Relatives are explicitly involved in the treatment process.
3.2.4 Long-term care
Patients who can no longer live independently at home due to cognitive or physical impairments are
eligible for long-term care. Many patients in long-term care suffer grom severe cognitive disorders, in
those cases direct treatment is not possible.
3.2.5 Forensic care
The neuropsychologist working in forensic care sees patients with a (suspected) mental disorder or
previously acquired brain injury. Treatment of patients can be voluntary or imposed.
Neuropsychologists in forensic institutions often work within a legal framework. They may also focus
on risk assessment, estimating the extent to which cognitive impairment and other personal
characteristics will influence re-offending. The forensic neuropsychologist is also involved in the
question of whether statements made my suspects or victims are reliable.
3.3 Neuropsychological assessment
3.3.1 The neuropsychological examination
A neuropsychological examination consists of a complete, hypothesis-testing diagnostic cycle, which
is basically similar to the empirical cycle used in scientific research.
1. Referral question: before setting up a neuropsychological examination, the aim of the
assessment must be clear.
2. Patient file investigation: including the medical and psychiatric history and whether a
(neuro)psychological examination has been conducted before.
3. Hypotheses: and a specific set of neuropsychological tests and questionnaires is filed.
4. Extensive clinical interview: complaints experienced by the patient, course of the complaints,
extent to which they limit in daily activities, mood, sleeping pattern, changes in character or
emotions and an interview with an information, in most cases a family member.
5. Psychometric test examination: consists of various tests and questionnaires. Performance on a
test and the way they achieve this performance are important. Observations outside the test
examination also contribute to the overall picture of a patient.
6. Conclusion: information is combined and weighed and the referrer’s question is answered.
A neuropsychological examination is often demanding and stressful for patients. In addition, patients
may be stressed about possible diagnoses. Finally, the duration and intensity of a neuropsychological
examination requires considerable mental effort from patients. One must collect sufficient information
to answer the question, but the patient must not be burdened unnecessarily.
,A standardised set of tests can be useful when it is tailored to a specific patient population and a
statement about the cognitive profile must be made. However, if the diagnostic process is not finished
yet and there are still several differential diagnostic considerations, it is preferable to expand and/or
tailor the set of tests to the individual patient.
It is important to make a clear distinction between reported complaints and objectified disorders. It is
often difficult for patients to identify the underlying cause of their symptoms. In addition, a patient
may also experience symptoms that are primarily triggered by anxiety.
During a neuropsychological examination, psychosocial and personality factors are also taken into
account. Somatic or psychiatric comorbidity may also play a role in the development or course of the
symptoms.
3.2.2 Reliability, validity, and confounding factors
When selecting tests for a neuropsychological examination, it is important to look critically at the
reliability and validity of a test.
- Test-retest reliability: the extent to which a test leads to the same result if it is administered to
the same patient at different times
- Inter-reliability: the extent to which different researches come to the same result when a test is
administered under similar conditions
Validity: the extent to which a test measures what it is intended to measure
- Face validity: the extent to which a test measures what is supposed to measure at first sight
- Content validity: the extent to which the test is representative of the subject to be measured
- Concept validity (or construct validity): the extent to which the result of the test is actually an
indication of the cognitive function one wants to make a statement about
- Criterion validity: the extent to which a test can predict a patient's performance on an external
criterion
- Predictive validity: the extent to which a test can predict actual behaviour
- Concurrent validity: the comparison between a neuropsychological test and another instrument
that measures the same construct
- Ecological validity: the extent to which a test predicts how a patient will function in their own
daily environment. A specific form of predictive validity
A confounding factor influences test performance, but is not related to what the test claims to measure.
Fatigue is a well-known confounding factor. Pain can also be seen as a confounding factor, as can
tension and uncertainty of a patient during test taking. All these factors can lead to significantly lower
test performances.
A specific confounding factor that a neuropsychologist must take into account is a limited commitment
or motivation for tests or distorted reporting of complaints. This can lead to under-performance: a
patient performs worse than they are actually capable of; or to over-reporting: reports more symptoms
or exaggerates them; thus creating a distortion of the actual symptoms and limitations. In the lack of
awareness of illness (anosognosia), the patient is not aware of their disease and the accompanying
limitations. It is also possible that patients consciously show a poor performance because there is an
interest in being seen as affected or ill. A distinction can be made between exaggerating complaints
(aggravating) and pretending non-existent cognitive complaints (simulating)
It is recommended that two performance validity tests are always included in the neuropsychological
examination. In addition, so-called embedded validity indicators can be used.
, When determining a cut-off point for a performance validity test, the ideal balance between sensitivity
and specificity is always sought. The aim is to detect as many cases of patients showing poor effort as
possible but at the same time prevent false positives as patients will be wrongly accused of displaying
insufficient effort.
3.3.3 Norms and classification
After the examination is completed, the data from tests and questionnaires must be scored and
standardised. Extensive norms are available for some neuropsychological tests, based on a large group
of healthy participants and specifically tailored to the country in which the test is administered. It is
also possible to compare the entire profile of a patient’s test scores with a group of healthy controls,
so-called multivariate normative comparisons.
Recommendations for internation and more uniform labels are as follows: seven intervals of the
Gaussian/normal distribution, ranging from exceptionally high to above average, high average,
average, low average, below average to exceptionally low.
3.3.4 Clinical guidelines
Ideally, a neuropsychological examination is patient tailored. Guidelines offer tools for drawing up a
core set of tests and questionnaires for specific groups of patients. In guidelines, scientific knowledge
is translated into recommendations for clinical practice. Scientific evidence, however, is often
inconclusive. Guidelines are therefore based on the scientific consensus or views most researchers and
clinicians agree on.
Specific situations may force the examiner to deviate from the guidelines. Deviating from the
guidelines is allowed and sometimes necessary, but the neuropsychologist must be able to clearly
motivate this.
The basic principles on which the code of ethics is based are responsibility, integrity, respect and
expertise. The professional code (AST / NIP) protects a client or patient against possible careless
actions by the psychologist. Apart from the general rights and obligations described within the
professional code, three patient rights need to be underlined when they are the subject of
neuropsychological examination:
1. The right to view the report before it is issued
2. The right to correction (in the event of factual inaccuracies)
3. The right to block the report from being issued
3.3.5 Neuropsychological experts report
In a medicolegal report, it is important to provide patients with a detailed explanation of the procedure
prior to the investigation and to point out their rights. In addition, controlling for performance and
symptom validity is an essential part of the neuropsychological medicolegal report, for which
performance validity tests and symptom validity questionnaires or embedded validity indicators must
be used.
3.1 Introduction
A psychologist working in health care is a scientist-practitioner who combines clinical knowledge and
skills with a scientific attitude. The decisions of the neuropsychologist are based on evidence from
scientific research on one hand, and clinical expertise and individual patient needs on the other hand.
Assessment process:
1. Research question
2. Various hypotheses are formulated
3. Data collection (studying the medical file, clinical interview, interview with an informant,
observations, test results, questionnaires)
4. Results are integrated
5. Conclusion
3.2 Areas of expertise
3.2.1 Hospital
Many neuropsychologists work in a hospital setting. A categorical hospital focuses on a specific
patient group. Care in a university hospital is usually closely intertwined with scientific research and
there is a direct collaboration with a university. Within the hospital neuropsychologists collaborate
together with various medical specialists and paramedics. Questions that the neuropsychologist in the
hospital encounters are often focused on diagnostics. By conduction a neuropsychological assessment,
the neuropsychologist maps out the cognitive, emotional and behavioural functioning of a patient and
determines whether the profile fits the (suspected) disorder. In addition, a neuropsychological
assessment is used to describe the consequences of cognitive impairment and its impact on patients’
daily lives. Besides diagnostic questions, the neuropsychologist within a hospital focuses on
treatments mostly of short duration.
3.2.2 Mental health care
Several psychiatric disorders are known to have an effect ton cognitive function, or cognitive
impairments are associated with the disorder itself. Cognitive dysfunctions can also explain specific
neuropsychiatric problems, such as cognitive bias in people with depression or disturbances in
temporal context memory as a mechanism of confabulations. However, it is also possible that after
brain damage, changes in behaviour or personality occur or that psychiatric symptoms develop.
The neuropsychologist within a mental health institution makes use of a neuropsychiatric model,
which examines the relationship between brain, cognition, emotion and behaviour. Both
comprehensive diagnostics and treatment are covered. The diagnostic process is often used to
investigate the cause of the cognitive symptoms reported by patients. Treatment in the mental health
services often last longer than treatments in a hospital.
,3.2.3 Rehabilitation care
In rehabilitation, a multidisciplinary approach is taken, with the patient’s treatment team made up of
the neuropsychologist and other disciplines. Treatment can take place in both inpatient and outpatient
settings. A key theme in rehabilitation is participation: the aim is to enable patients to participate in
activities in society as independently as possible. The neuropsychologist also pays attention to how
patients deal with problems (coping). Coping styles and personality factors play a role in how patients
cope with their condition. Relatives are explicitly involved in the treatment process.
3.2.4 Long-term care
Patients who can no longer live independently at home due to cognitive or physical impairments are
eligible for long-term care. Many patients in long-term care suffer grom severe cognitive disorders, in
those cases direct treatment is not possible.
3.2.5 Forensic care
The neuropsychologist working in forensic care sees patients with a (suspected) mental disorder or
previously acquired brain injury. Treatment of patients can be voluntary or imposed.
Neuropsychologists in forensic institutions often work within a legal framework. They may also focus
on risk assessment, estimating the extent to which cognitive impairment and other personal
characteristics will influence re-offending. The forensic neuropsychologist is also involved in the
question of whether statements made my suspects or victims are reliable.
3.3 Neuropsychological assessment
3.3.1 The neuropsychological examination
A neuropsychological examination consists of a complete, hypothesis-testing diagnostic cycle, which
is basically similar to the empirical cycle used in scientific research.
1. Referral question: before setting up a neuropsychological examination, the aim of the
assessment must be clear.
2. Patient file investigation: including the medical and psychiatric history and whether a
(neuro)psychological examination has been conducted before.
3. Hypotheses: and a specific set of neuropsychological tests and questionnaires is filed.
4. Extensive clinical interview: complaints experienced by the patient, course of the complaints,
extent to which they limit in daily activities, mood, sleeping pattern, changes in character or
emotions and an interview with an information, in most cases a family member.
5. Psychometric test examination: consists of various tests and questionnaires. Performance on a
test and the way they achieve this performance are important. Observations outside the test
examination also contribute to the overall picture of a patient.
6. Conclusion: information is combined and weighed and the referrer’s question is answered.
A neuropsychological examination is often demanding and stressful for patients. In addition, patients
may be stressed about possible diagnoses. Finally, the duration and intensity of a neuropsychological
examination requires considerable mental effort from patients. One must collect sufficient information
to answer the question, but the patient must not be burdened unnecessarily.
,A standardised set of tests can be useful when it is tailored to a specific patient population and a
statement about the cognitive profile must be made. However, if the diagnostic process is not finished
yet and there are still several differential diagnostic considerations, it is preferable to expand and/or
tailor the set of tests to the individual patient.
It is important to make a clear distinction between reported complaints and objectified disorders. It is
often difficult for patients to identify the underlying cause of their symptoms. In addition, a patient
may also experience symptoms that are primarily triggered by anxiety.
During a neuropsychological examination, psychosocial and personality factors are also taken into
account. Somatic or psychiatric comorbidity may also play a role in the development or course of the
symptoms.
3.2.2 Reliability, validity, and confounding factors
When selecting tests for a neuropsychological examination, it is important to look critically at the
reliability and validity of a test.
- Test-retest reliability: the extent to which a test leads to the same result if it is administered to
the same patient at different times
- Inter-reliability: the extent to which different researches come to the same result when a test is
administered under similar conditions
Validity: the extent to which a test measures what it is intended to measure
- Face validity: the extent to which a test measures what is supposed to measure at first sight
- Content validity: the extent to which the test is representative of the subject to be measured
- Concept validity (or construct validity): the extent to which the result of the test is actually an
indication of the cognitive function one wants to make a statement about
- Criterion validity: the extent to which a test can predict a patient's performance on an external
criterion
- Predictive validity: the extent to which a test can predict actual behaviour
- Concurrent validity: the comparison between a neuropsychological test and another instrument
that measures the same construct
- Ecological validity: the extent to which a test predicts how a patient will function in their own
daily environment. A specific form of predictive validity
A confounding factor influences test performance, but is not related to what the test claims to measure.
Fatigue is a well-known confounding factor. Pain can also be seen as a confounding factor, as can
tension and uncertainty of a patient during test taking. All these factors can lead to significantly lower
test performances.
A specific confounding factor that a neuropsychologist must take into account is a limited commitment
or motivation for tests or distorted reporting of complaints. This can lead to under-performance: a
patient performs worse than they are actually capable of; or to over-reporting: reports more symptoms
or exaggerates them; thus creating a distortion of the actual symptoms and limitations. In the lack of
awareness of illness (anosognosia), the patient is not aware of their disease and the accompanying
limitations. It is also possible that patients consciously show a poor performance because there is an
interest in being seen as affected or ill. A distinction can be made between exaggerating complaints
(aggravating) and pretending non-existent cognitive complaints (simulating)
It is recommended that two performance validity tests are always included in the neuropsychological
examination. In addition, so-called embedded validity indicators can be used.
, When determining a cut-off point for a performance validity test, the ideal balance between sensitivity
and specificity is always sought. The aim is to detect as many cases of patients showing poor effort as
possible but at the same time prevent false positives as patients will be wrongly accused of displaying
insufficient effort.
3.3.3 Norms and classification
After the examination is completed, the data from tests and questionnaires must be scored and
standardised. Extensive norms are available for some neuropsychological tests, based on a large group
of healthy participants and specifically tailored to the country in which the test is administered. It is
also possible to compare the entire profile of a patient’s test scores with a group of healthy controls,
so-called multivariate normative comparisons.
Recommendations for internation and more uniform labels are as follows: seven intervals of the
Gaussian/normal distribution, ranging from exceptionally high to above average, high average,
average, low average, below average to exceptionally low.
3.3.4 Clinical guidelines
Ideally, a neuropsychological examination is patient tailored. Guidelines offer tools for drawing up a
core set of tests and questionnaires for specific groups of patients. In guidelines, scientific knowledge
is translated into recommendations for clinical practice. Scientific evidence, however, is often
inconclusive. Guidelines are therefore based on the scientific consensus or views most researchers and
clinicians agree on.
Specific situations may force the examiner to deviate from the guidelines. Deviating from the
guidelines is allowed and sometimes necessary, but the neuropsychologist must be able to clearly
motivate this.
The basic principles on which the code of ethics is based are responsibility, integrity, respect and
expertise. The professional code (AST / NIP) protects a client or patient against possible careless
actions by the psychologist. Apart from the general rights and obligations described within the
professional code, three patient rights need to be underlined when they are the subject of
neuropsychological examination:
1. The right to view the report before it is issued
2. The right to correction (in the event of factual inaccuracies)
3. The right to block the report from being issued
3.3.5 Neuropsychological experts report
In a medicolegal report, it is important to provide patients with a detailed explanation of the procedure
prior to the investigation and to point out their rights. In addition, controlling for performance and
symptom validity is an essential part of the neuropsychological medicolegal report, for which
performance validity tests and symptom validity questionnaires or embedded validity indicators must
be used.
