Week 1: Introduction
Objective markers
Term Example
1. Reduce costs and liability - Young man suffers TBI in an accident
- Assessment shows that extent and nature of impairments reduce man’s
capacity to maintain line of work for which he was trained
- Consequently: Hundreds of thousands of lost dollars as a result of brain
injury
- Because of neuropsychological assessment consequences of accident
documented
o Capturing most of the man’s lost income via litigation
o Reduction of costs for society by neuropsychological
medicolegal assessment of around $3,000
Extra:
- Savings associated with identification of malingerers
- Savings associated with differential diagnosis on bass of NPA (f.e.
between dementia and depression)
o Psychiatric treatment available for depression
Which might result in productive lifestyle of people
with depression
o If neuropsychological findings are indicative of early dementia
People with dementia and their families can plan for
the early significant decline in cognitive and
behavioral functioning
2. Improve QOL - 53-year-old male treated for a brain tumor (surgery and radiotherapy)
- Owner of a big furniture store
- After treatment NO neuropsychological assessment
- Bad financial decisions and investments
- Bankruptcy after 18 months post treatment with considerable debts
- Neuropsychological assessment at this time revealed impairments in
executive functioning and working memory
- Subjective complaint: Co-workers and friends laugh at him since time of
surgery
3. Assess the effectiveness Pharmacological treatment, neurosurgery, neurofeedback, cognitive trainings, etc.
of treatment
4. Guide treatment Neuropsychological findings contribute significantly to decision whether someone
procedures undergoes epilepsy surgery
5. Prevent the use of more Neuropsychological findings can better predict the diagnosis Alzheimer’s disease
expensive/additional than other techniques (i.e., CSF and PET)
diagnostic tools
6. Provide a continuum of Clinical neuropsychologists consult with affected people and their families about
care the deficits
- Prepares them to deal with intermediate and long-term consequences
of a person’s brain dysfunctions
7. Improve physician Affected people and their families may suffer from pain, stress and
education and decision economic burden when a person returns prematurely to work
making
1
, Subjective markers
Term Example
1. Reduce a person’s Relief of a person with a brain tumor (“I am not mad”) when describing an
sense of psychological association between deficits and tumor location to her
aloneness with daily
problems
2. Reduce a person’s Affected people and their families often have unrealistic expectations or wrong
expectations confusion understandings about deficits and their development
and frustration about
the nature of their
disturbances
3. Help family members - Many families struggle with the issue of placing a loved-one in a
feels less guilty in residential/nursing home
making decisions - In children: Often considerable relief when parents learn that problems
regarding brain- (e.g. ADHD) are not the consequence of “poor” parenting or
dysfunctional adults psychodynamic processes
and children Example:
- Feelings of guilt and self-reproach of father who slapped daughter in the
face and who got a brain tumor diagnosed 10 days later
Which behaviors are likely to create problems?
1) Impaired social perception and social awareness
- Some people display a childlike egocentricity
- People might be un able to appreciate that their caretaker is tired or depressed or that their behavior
frightens their minor children
- People might not appreciate the social requirements of a setting and embarrass their companions with
noisy or inappropriate behavior:
o Feeling may arise that social outings with an affected person might cease to be worth the
effort or embarrassment
- Old friends might no longer visit:
o Isolation of the affected person, caretaker and other family members
2) Impaired control
- Impulsivity
o Anger, eating, sexuality, finance, substance abuse or driving
- Restlessness and agitation
- Impatience
3) Dependency
- Emotional dependency:
o Risk of vicious circles
o The more an affected person clings, the more obvious becomes the spouse’s impatience
and dissatisfaction, and the more frantic the affected person’s efforts to keep their
spouses under their immediate surveillance and control
o Vastklampen → Partner wordt ongeduldig en ontevreden → Meer controlepogingen →
Vicieuze cirkel
- Dependency resulting from cognitive difficulties (e.g. memory or planning difficulties)
o Example:
Struggle with daily activities → Need instructions or prompts
Can learn routines → But cannot handle change or novelty
Families may misinterpret → Seen as laziness or lack of motivation
- Dependence on physical care
- Dependence on financial support
4) Inability to learn from experience
- Even when inappropriate behavior repeatedly leads to trouble
o Many people do not change course
- Consequently: Family must treat each situation as though it is new and protect the affected person from
potential problems
o Requires constant vigilance from the family
5) Anxiety, depression and paranoia
2
, - Anxiety
o Families might see the affected person as inexplicably withdrawn, fearful, easily upset and
moody
o Families are helpless to do anything
- Depression
o A person’s depression particularly tends to erode family members’ self-esteem and
enhance feelings of guilt and inadequacy
o Because it is very resistant to their efforts to relieve it
- Paranoia
o Might develop because of:
Lack of insight
Feelings of worthlessness because of incompetency's
Fears of rejection because of those incompetency's
o Examples:
Concern of impotent male about the fidelity of his spouse
Suspiciousness about what others are doing with the affected person’s money
Be aware: When the affected person needs exceed the families’ capacities and the affected person’s care must be obtained
outside the families:
- Many family members (particularly the caretakers) feel guilty
- They feel ashamed and perceive that it is their failure to care for the affected person properly
Experiences of different family members:
1. The Affected Person’s Parent:
- Parents feel stress, no matter how old the child is.
- Parents are responsible for care until the person passes away.
- Marital problems often happen because parents argue about caregiving.
- Fathers might feel ignored as mothers usually do most of the caregiving.
- Marriages may end after a child’s brain impairment starts.
2. The Affected Person’s Minor Child or Sibling:
- Less attention from parents and more responsibilities.
- Feelings of shame, frustration, and anger about having a “different” family.
- It’s hard to do activities needing a parent’s help, because the parent is focused on the affected person.
- Loss of fun family moments, like vacations.
3. The Affected Person’s Partner or Spouse:
- Spouses lose emotional support and affection, which is especially needed now.
- They feel responsible, guilty, and worried about being judged by others, making it hard to think about
divorce.
- Spouses not only care for the affected person but also become targets for anger and frustration.
- Depression is common in spouses.
3
, Week 2: Fatigue
Introduction
Fatigue
- Significant proportion of general population affected by excessive fatigue
- One of the most common complaints reported to primary care physicians:
o Frequent and prolonged tiredness interfering with everyday life in about 27% of people in primary
care settings
Differentiation between “pathological fatigue” and “non-pathological fatigue”
- Is that pathological fatigue is characterizes by:
o Greater intensity
o Longer duration (months)
o More disabling effects on functional activities
o Remains after rest as a severe condition
- Pathological fatigue is characterized by a combination of all of these features!
Fatigue is viewed both as a:
Symptom Disease
Fatigue = Often reported as the most disabling symptom Fatigue = Often part of a group of “unexplained” illnesses
in many diseases by affecting a person’s physical, (e.g., chronic fatigue syndrome) with little understanding
psychological and social well-being. of its causes.
Fatigue = Nonspecific symptom, because it can be - Chronic fatigue syndrome (CFS) = Persistent
indicative of many causes or conditions: debilitating fatigue lasting for at least 6 months
- Neurological conditions (e.g., traumatic brain not due to ongoing exertion, not substantially
injury, multiple sclerosis, stroke, Parkinson's relieved by rest, and not caused by other medical
disease) conditions
- Psychiatric disorders (e.g., depression, - Chronic fatigue = Estimated to occur in about 4%
somatoform disorders) to 5% of general population (Jason et al., 1999)
- Medical conditions (e.g., infections, cancer,
coronary heart disease, thyroid abnormalities)
- Medications (e.g., antihistamines,
chemotherapy)
- Unhealthy lifestyles (e.g., sleep deprivation)
Defining fatigue
- "Fatigue" is commonly used in everyday and scientific discussions.
- However, there is no agreed-upon definition
- This makes it hard to fully understand fatigue's clinical effects.
Fatigue can be understood in two ways:
1. Subjective feeling: This emphasizes the individual’s personal experience of fatigue
o Like a lack of physical or mental energy that interferes with normal activities, as defined by the
Multiple Sclerosis Council for Clinical Practice Guidelines (1998).
2. Performance decrement: This focuses on objective changes in performance
o Such as a decrease in maximal force or power output during exercise, as described by Vollestad
(1997).
Clinically, fatigue is usually defined in terms of the person’s subjective experience of fatigue. Some clinical definitions of
fatigue include:
1. Fatigue is the awareness of reduced capacity for physical or mental activity due to an imbalance in the availability,
use, or restoration of resources needed for activity (Aaronson et al., 1999)
2. Fatigue is a state of weariness linked to reduced motivation, prolonged mental activity, or boredom, often seen in
chronic stress, anxiety, or depression (Lee et al., 1991)
Problem:
- There is a poor correlation between subjective experiences of fatigue and behavioral (or objective, performance-
based) measures this lack of correlation is making it harder to fully understand fatigue.
4
Objective markers
Term Example
1. Reduce costs and liability - Young man suffers TBI in an accident
- Assessment shows that extent and nature of impairments reduce man’s
capacity to maintain line of work for which he was trained
- Consequently: Hundreds of thousands of lost dollars as a result of brain
injury
- Because of neuropsychological assessment consequences of accident
documented
o Capturing most of the man’s lost income via litigation
o Reduction of costs for society by neuropsychological
medicolegal assessment of around $3,000
Extra:
- Savings associated with identification of malingerers
- Savings associated with differential diagnosis on bass of NPA (f.e.
between dementia and depression)
o Psychiatric treatment available for depression
Which might result in productive lifestyle of people
with depression
o If neuropsychological findings are indicative of early dementia
People with dementia and their families can plan for
the early significant decline in cognitive and
behavioral functioning
2. Improve QOL - 53-year-old male treated for a brain tumor (surgery and radiotherapy)
- Owner of a big furniture store
- After treatment NO neuropsychological assessment
- Bad financial decisions and investments
- Bankruptcy after 18 months post treatment with considerable debts
- Neuropsychological assessment at this time revealed impairments in
executive functioning and working memory
- Subjective complaint: Co-workers and friends laugh at him since time of
surgery
3. Assess the effectiveness Pharmacological treatment, neurosurgery, neurofeedback, cognitive trainings, etc.
of treatment
4. Guide treatment Neuropsychological findings contribute significantly to decision whether someone
procedures undergoes epilepsy surgery
5. Prevent the use of more Neuropsychological findings can better predict the diagnosis Alzheimer’s disease
expensive/additional than other techniques (i.e., CSF and PET)
diagnostic tools
6. Provide a continuum of Clinical neuropsychologists consult with affected people and their families about
care the deficits
- Prepares them to deal with intermediate and long-term consequences
of a person’s brain dysfunctions
7. Improve physician Affected people and their families may suffer from pain, stress and
education and decision economic burden when a person returns prematurely to work
making
1
, Subjective markers
Term Example
1. Reduce a person’s Relief of a person with a brain tumor (“I am not mad”) when describing an
sense of psychological association between deficits and tumor location to her
aloneness with daily
problems
2. Reduce a person’s Affected people and their families often have unrealistic expectations or wrong
expectations confusion understandings about deficits and their development
and frustration about
the nature of their
disturbances
3. Help family members - Many families struggle with the issue of placing a loved-one in a
feels less guilty in residential/nursing home
making decisions - In children: Often considerable relief when parents learn that problems
regarding brain- (e.g. ADHD) are not the consequence of “poor” parenting or
dysfunctional adults psychodynamic processes
and children Example:
- Feelings of guilt and self-reproach of father who slapped daughter in the
face and who got a brain tumor diagnosed 10 days later
Which behaviors are likely to create problems?
1) Impaired social perception and social awareness
- Some people display a childlike egocentricity
- People might be un able to appreciate that their caretaker is tired or depressed or that their behavior
frightens their minor children
- People might not appreciate the social requirements of a setting and embarrass their companions with
noisy or inappropriate behavior:
o Feeling may arise that social outings with an affected person might cease to be worth the
effort or embarrassment
- Old friends might no longer visit:
o Isolation of the affected person, caretaker and other family members
2) Impaired control
- Impulsivity
o Anger, eating, sexuality, finance, substance abuse or driving
- Restlessness and agitation
- Impatience
3) Dependency
- Emotional dependency:
o Risk of vicious circles
o The more an affected person clings, the more obvious becomes the spouse’s impatience
and dissatisfaction, and the more frantic the affected person’s efforts to keep their
spouses under their immediate surveillance and control
o Vastklampen → Partner wordt ongeduldig en ontevreden → Meer controlepogingen →
Vicieuze cirkel
- Dependency resulting from cognitive difficulties (e.g. memory or planning difficulties)
o Example:
Struggle with daily activities → Need instructions or prompts
Can learn routines → But cannot handle change or novelty
Families may misinterpret → Seen as laziness or lack of motivation
- Dependence on physical care
- Dependence on financial support
4) Inability to learn from experience
- Even when inappropriate behavior repeatedly leads to trouble
o Many people do not change course
- Consequently: Family must treat each situation as though it is new and protect the affected person from
potential problems
o Requires constant vigilance from the family
5) Anxiety, depression and paranoia
2
, - Anxiety
o Families might see the affected person as inexplicably withdrawn, fearful, easily upset and
moody
o Families are helpless to do anything
- Depression
o A person’s depression particularly tends to erode family members’ self-esteem and
enhance feelings of guilt and inadequacy
o Because it is very resistant to their efforts to relieve it
- Paranoia
o Might develop because of:
Lack of insight
Feelings of worthlessness because of incompetency's
Fears of rejection because of those incompetency's
o Examples:
Concern of impotent male about the fidelity of his spouse
Suspiciousness about what others are doing with the affected person’s money
Be aware: When the affected person needs exceed the families’ capacities and the affected person’s care must be obtained
outside the families:
- Many family members (particularly the caretakers) feel guilty
- They feel ashamed and perceive that it is their failure to care for the affected person properly
Experiences of different family members:
1. The Affected Person’s Parent:
- Parents feel stress, no matter how old the child is.
- Parents are responsible for care until the person passes away.
- Marital problems often happen because parents argue about caregiving.
- Fathers might feel ignored as mothers usually do most of the caregiving.
- Marriages may end after a child’s brain impairment starts.
2. The Affected Person’s Minor Child or Sibling:
- Less attention from parents and more responsibilities.
- Feelings of shame, frustration, and anger about having a “different” family.
- It’s hard to do activities needing a parent’s help, because the parent is focused on the affected person.
- Loss of fun family moments, like vacations.
3. The Affected Person’s Partner or Spouse:
- Spouses lose emotional support and affection, which is especially needed now.
- They feel responsible, guilty, and worried about being judged by others, making it hard to think about
divorce.
- Spouses not only care for the affected person but also become targets for anger and frustration.
- Depression is common in spouses.
3
, Week 2: Fatigue
Introduction
Fatigue
- Significant proportion of general population affected by excessive fatigue
- One of the most common complaints reported to primary care physicians:
o Frequent and prolonged tiredness interfering with everyday life in about 27% of people in primary
care settings
Differentiation between “pathological fatigue” and “non-pathological fatigue”
- Is that pathological fatigue is characterizes by:
o Greater intensity
o Longer duration (months)
o More disabling effects on functional activities
o Remains after rest as a severe condition
- Pathological fatigue is characterized by a combination of all of these features!
Fatigue is viewed both as a:
Symptom Disease
Fatigue = Often reported as the most disabling symptom Fatigue = Often part of a group of “unexplained” illnesses
in many diseases by affecting a person’s physical, (e.g., chronic fatigue syndrome) with little understanding
psychological and social well-being. of its causes.
Fatigue = Nonspecific symptom, because it can be - Chronic fatigue syndrome (CFS) = Persistent
indicative of many causes or conditions: debilitating fatigue lasting for at least 6 months
- Neurological conditions (e.g., traumatic brain not due to ongoing exertion, not substantially
injury, multiple sclerosis, stroke, Parkinson's relieved by rest, and not caused by other medical
disease) conditions
- Psychiatric disorders (e.g., depression, - Chronic fatigue = Estimated to occur in about 4%
somatoform disorders) to 5% of general population (Jason et al., 1999)
- Medical conditions (e.g., infections, cancer,
coronary heart disease, thyroid abnormalities)
- Medications (e.g., antihistamines,
chemotherapy)
- Unhealthy lifestyles (e.g., sleep deprivation)
Defining fatigue
- "Fatigue" is commonly used in everyday and scientific discussions.
- However, there is no agreed-upon definition
- This makes it hard to fully understand fatigue's clinical effects.
Fatigue can be understood in two ways:
1. Subjective feeling: This emphasizes the individual’s personal experience of fatigue
o Like a lack of physical or mental energy that interferes with normal activities, as defined by the
Multiple Sclerosis Council for Clinical Practice Guidelines (1998).
2. Performance decrement: This focuses on objective changes in performance
o Such as a decrease in maximal force or power output during exercise, as described by Vollestad
(1997).
Clinically, fatigue is usually defined in terms of the person’s subjective experience of fatigue. Some clinical definitions of
fatigue include:
1. Fatigue is the awareness of reduced capacity for physical or mental activity due to an imbalance in the availability,
use, or restoration of resources needed for activity (Aaronson et al., 1999)
2. Fatigue is a state of weariness linked to reduced motivation, prolonged mental activity, or boredom, often seen in
chronic stress, anxiety, or depression (Lee et al., 1991)
Problem:
- There is a poor correlation between subjective experiences of fatigue and behavioral (or objective, performance-
based) measures this lack of correlation is making it harder to fully understand fatigue.
4
