Brain & Cognition 2: Clinical
Neuropsychology
2020-2021
Introduction to Clinical Neuropsychology
- Chapter 2 -
This lecture:
Overview of neuropsychological diagnostics and cognitive rehabilitation
Working model currently used in clinical practice
Explain the main objectives and questions
Examine the role of neuropsychological testing
Address the role of diagnostics in cognitive rehabilitation
Discuss the typical objectives for treating patients with brain damage or brain disorders
Summary:
Neuropsychologists carry out tests, integrate tests, observations and interviews in a
scientific manner. This requires knowledge of diseases, disorders, as well as validity,
reliability, and normative data for the different neuropsychological tests.
Neuropsychology evaluates the behavioral effects of a disease, gives advice to the people
that are close to the patient and helps to choose the most appropriate treatment.
Clinical Neuropsychology
“Scientific area that studies the relations between brain and behaviour especially the clinical
applicability of assessment, treatment, and care of individuals with (presumed) cognitive
(dys)function as a result of developmental disorders, neurological disorders (brain diseases or
damage), or psychiatric disorders.”
Behaviour in a broad sense
Behavioural symptoms can be all kind of latent variables that objectively can be assessed through
tests. But besides that, it is also important to take notice of subjective variables. They can be
observed by the patient and significant others.
Neuropsychologists are scientist practitioners:
Use knowledge of neuropsychological symptoms;
Test methods to diagnose and treat brain disorders in patients;
Because of their broad expertise, they are ideally suited to manage the treatment for people
with cognitive, emotional, and behavioral disorders as well as for those with brain injuries.
Diagnostic cycle
1. Complaint analysis stage: interviewing patients and informants.
2. Problem analysis stage: the problem is analysed through different tests.
3. Diagnosis stage: a diagnosis is made based on the previously gathered information.
4. Indication-for-treatment stage: the need for further diagnostics or options for treatment is
examined.
1
,The neuropsychological assessment follows a diagnostic cycle of the four stages described above. In
each stage, hypotheses are formulated and tested, and these hypotheses can be changed or rejected
throughout the diagnostic cycle. The four stages often overlap. The entire diagnostic cycle is not
always completed. Sometimes it can occur that after for example the complaint analysis stage, not
to conduct a test because it will have no added value.
A symptom validity test can signal possible underperformance or over-reporting of symptoms.
Interviewing the informant is essential because many patients are not able to provide reliable
information about their complaints of daily life functioning. However, the information of the
informant is subjective and might not be representative of the actual situation of the patient. The
patient needs to give permission to let the neuropsychologist interview the informant. This often
happens without the presence of the patient.
Emotional overload of the informant overreporting of complaints and changes
Acceptance problems of the informant minimize the complaints
Another element of a neuropsychological examination is the recording of observations during the
interview, the tests, and outside the examination room. It is essential that observations are free
from interpretations, that they are objective. Poor performance on a test doesn’t always mean that
there is a cognitive disorder.
A fixed test battery consists of multiple tests that are always the same for every patient. This
method is frequently used for the evaluation of treatments for scientific research. Which test is
chosen for a specific patient depends on the referral question, the complaints and the psychometric
properties. Important factors to consider are: reliability, validity, normative data, discriminative
power (sensitivity and specificity), and the availability of parallel versions. Computerized testing is
used a lot because of the high level of standardization, accurate recording and time saving (attention
and reaction time tasks). However, they lack opportunities for qualitative observations and therefore
can lose significance.
Sensitivity is the likelihood that a test will identify a person with a disorder as ‘disturbed’ true
positive. Specificity is the likelihood that a test will identify a person without a disorder as ‘not
disturbed’ true negative. High sensitivity and low specificity often go hand in hand, just as high
specificity with low sensitivity. Neuropsychologists often choose a test that has a high sensitivity,
because any cognitive disorder should not be missed. Prevalence refers to the number of cases of a
specific disorder that occurs within a particular number of people. Incidence refers to the number of
new cases of the disorder that occurs within a specified period.
During the interpretation you have to check whether the test results are reliable, valid, and truly
reflect the level of cognitive or emotional functioning of the patient. If the tests don’t indicate a
cognitive disorder, it doesn’t immediately mean that there is no brain injury or disorder.
Reliability
The reliability of a test refers to the accuracy of the instrument.
Test-retest reliability: indicates the extent to which a test yields the same results when it is
taken at different times by the same patient. It is indicated by a correlation coefficient.
Inter-rater reliability: indicates the correspondence between the results of the same test
administered by various researchers and is presented as Cohen’s kappa.
2
,Validity
The validity answers the question whether the test measures what it is supposed to measure. Only
because a test measures what it is supposed to measure (face validity) doesn’t mean that it predicts
the patient’s function in everyday life (ecological validity).
Face validity: the extent to which a test initially measures what it is supposed to measure.
Content validity: the extent to which a test is representative of the topic that is to be
measured.
Construct validity: the extent to which the result of a test reflects the cognitive function (the
construct) that is being assessed.
Criterion validity: the extent to which a test can predict the performance of a patient about
an external criterion (e.g. social performance).
o Predictive validity: how accurately a test predicts actual behavior
o Concurrent validity: the difference between a neuropsychological test and another
tool that aims to measure the same criterion.
Ecological validity: the extent to which a test predicts the patient’s daily functioning.
Underperformance can happen when someone is very tired, nervous, has complaints or anxiety
during the test or simulates or exaggerates cognitive complaints. When this won’t be noticed this
can lead to a wrong diagnosis of a disorder which can have adverse consequences for the patient
and society. Underperformance should be considered when a patient performs better on challenging
tasks than on easy ones and if a striking discrepancy between behavior and test performance occur
and/or if the patient’s complaints are not in accordance with the severity of the disorder. Sometimes
underperformance is intentional. When given a multiple choice test underperformance is indicated
when a score lies significantly below the level achieved by chance (Test Of Memory Malingering).
The neuropsychologist in…
… hospitals. In this institution the neuropsychologist has to carry out neuropsychological diagnostics:
to identify the cause of a complaint or to assess the effects of a recognized brain injury. Treatment is
often short-term, complaint-oriented and it usually implies psychoeducation. They also advise
nursing teams when dealing with challenging behavior in patients with a brain injury. They assess the
effectiveness of a treatment or intervention.
… rehabilitation centers. Neuropsychologists have a leading and coaching role in various treatment
teams for patients with a neurological disorder. The focus is more on treatment than on diagnostics,
though neuropsychological assessment is critical. Therapy in rehabilitation centers focuses not only
on cognitive disorders but also on coping mechanisms and complaints such as depression or anxiety.
… mental health care. Neuropsychologists play an essential role in drawing up a treatment plan.
They are also involved in meditative treatment, in which they try to influence the patient’s behavior
via the people who are most closely involved with the patient. These psychologists mostly encounter
patients with mood disorders, psychotic disorders, ADHD, addiction and autism spectrum disorder.
… residential homes, nursing homes, and supported housing. The main tasks of a neuropsychologist
are evaluating cognitive skills, exploring the cause and expected course of complaints, giving advice
about suitable living and care arrangements and showing possible ways of influencing behavior.
Treatment methods range from cognitive rehabilitation, psychotherapy, systemic therapy for
supporting families or couples, meditative therapy, and practical advice for carriers.
… forensic institutions. There is a neurobiological basis for ‘criminal’ behavior. Referral questions are
usually related to explanatory diagnostics or are used to support a treatment assessment. The
criteria for reporting are very strict, because a diagnosis can influence custody of the patient.
3
, Korsakoff’s Syndrome and Alcohol-related
Cognitive Disorders
- Chapter 18 -
This lecture:
Discuss Korsakoff’s syndrome and other disorders caused by alcohol abuse
Korsakoff’s syndrome is a condition caused by a serious vitamin B1 (thiamine) deficiency
Korsakoff’s syndrome is usually the result of alcohol addiction
Patients primarily lose the ability to learn new information, but are also increasingly unable to
perform their normal daily routine and to care for themselves.
Summary:
Chronic alcohol use can result in severe brain damage which leads to cognitive deterioration of
varying severity.
An additional vitamin B1 (thiamine) deficiency may result in Korsakoff syndrome, with severe
amnesia and executive impairments.
Heavy drinkers are more likely to develop executive problems and cerebrovascular
complications.
DSM-5 classification of Korsakoff syndrome emphasizes amnesia or confabulations, though most
patients also have executive problems.
A thorough analysis of cognitive impairments and psychological functioning in addition to
neuroimaging should be conducted to find explanations for the impairments of the patient.
Epidemiology
The average age of people requesting help with alcohol-related problems is around 45 years, and
75% of those people are male. Only a few people under the age of 25 seek help with alcohol use
disorder (AUD) (5%). Only 20% of patients who seek help at addiction treatment centers are there
for the first time. Alcohol-related problems are sometimes combined with other problematic drug
use or gambling addiction. Long-term and excessive alcohol consumption can result in cognitive
impairments that may be present long before alcohol-related neurological symptoms appear. These
impairments are the results of the alcohol damaging the nervous system in various ways:
Immediate neurotoxic effect on neurons and axons;
Indirect neurotoxic effects of high calcium concentrations in the neurons after
sudden withdrawal of alcohol;
Irreversible disruption of physiological processes caused by chronic vitamin
deficiency (especially thiamine).
Direct changes in cognitive functioning after alcohol consumption include increasing reaction time.
this is not necessarily bad (so when it isn’t structural use), it happens all the time with a lot of
people that are using alcohol.
Changes in cognitive functioning after excessive alcohol consumption affect explicit memory and
prospective memory. this isn’t normal anymore. You have to use it excessively for a longer
period. The ability to perceive and judge emotions and emotional facial expressions is decreased, as
well as response inhibition and behavioral control.
Neurotoxicity of alcohol
Alcohol has a sedating effect on brain functioning through stimulating effect on the GABA-system
and an inhibitory effect on NMDA-receptors of the glutamate-system. The stimulating effect on the
4
Neuropsychology
2020-2021
Introduction to Clinical Neuropsychology
- Chapter 2 -
This lecture:
Overview of neuropsychological diagnostics and cognitive rehabilitation
Working model currently used in clinical practice
Explain the main objectives and questions
Examine the role of neuropsychological testing
Address the role of diagnostics in cognitive rehabilitation
Discuss the typical objectives for treating patients with brain damage or brain disorders
Summary:
Neuropsychologists carry out tests, integrate tests, observations and interviews in a
scientific manner. This requires knowledge of diseases, disorders, as well as validity,
reliability, and normative data for the different neuropsychological tests.
Neuropsychology evaluates the behavioral effects of a disease, gives advice to the people
that are close to the patient and helps to choose the most appropriate treatment.
Clinical Neuropsychology
“Scientific area that studies the relations between brain and behaviour especially the clinical
applicability of assessment, treatment, and care of individuals with (presumed) cognitive
(dys)function as a result of developmental disorders, neurological disorders (brain diseases or
damage), or psychiatric disorders.”
Behaviour in a broad sense
Behavioural symptoms can be all kind of latent variables that objectively can be assessed through
tests. But besides that, it is also important to take notice of subjective variables. They can be
observed by the patient and significant others.
Neuropsychologists are scientist practitioners:
Use knowledge of neuropsychological symptoms;
Test methods to diagnose and treat brain disorders in patients;
Because of their broad expertise, they are ideally suited to manage the treatment for people
with cognitive, emotional, and behavioral disorders as well as for those with brain injuries.
Diagnostic cycle
1. Complaint analysis stage: interviewing patients and informants.
2. Problem analysis stage: the problem is analysed through different tests.
3. Diagnosis stage: a diagnosis is made based on the previously gathered information.
4. Indication-for-treatment stage: the need for further diagnostics or options for treatment is
examined.
1
,The neuropsychological assessment follows a diagnostic cycle of the four stages described above. In
each stage, hypotheses are formulated and tested, and these hypotheses can be changed or rejected
throughout the diagnostic cycle. The four stages often overlap. The entire diagnostic cycle is not
always completed. Sometimes it can occur that after for example the complaint analysis stage, not
to conduct a test because it will have no added value.
A symptom validity test can signal possible underperformance or over-reporting of symptoms.
Interviewing the informant is essential because many patients are not able to provide reliable
information about their complaints of daily life functioning. However, the information of the
informant is subjective and might not be representative of the actual situation of the patient. The
patient needs to give permission to let the neuropsychologist interview the informant. This often
happens without the presence of the patient.
Emotional overload of the informant overreporting of complaints and changes
Acceptance problems of the informant minimize the complaints
Another element of a neuropsychological examination is the recording of observations during the
interview, the tests, and outside the examination room. It is essential that observations are free
from interpretations, that they are objective. Poor performance on a test doesn’t always mean that
there is a cognitive disorder.
A fixed test battery consists of multiple tests that are always the same for every patient. This
method is frequently used for the evaluation of treatments for scientific research. Which test is
chosen for a specific patient depends on the referral question, the complaints and the psychometric
properties. Important factors to consider are: reliability, validity, normative data, discriminative
power (sensitivity and specificity), and the availability of parallel versions. Computerized testing is
used a lot because of the high level of standardization, accurate recording and time saving (attention
and reaction time tasks). However, they lack opportunities for qualitative observations and therefore
can lose significance.
Sensitivity is the likelihood that a test will identify a person with a disorder as ‘disturbed’ true
positive. Specificity is the likelihood that a test will identify a person without a disorder as ‘not
disturbed’ true negative. High sensitivity and low specificity often go hand in hand, just as high
specificity with low sensitivity. Neuropsychologists often choose a test that has a high sensitivity,
because any cognitive disorder should not be missed. Prevalence refers to the number of cases of a
specific disorder that occurs within a particular number of people. Incidence refers to the number of
new cases of the disorder that occurs within a specified period.
During the interpretation you have to check whether the test results are reliable, valid, and truly
reflect the level of cognitive or emotional functioning of the patient. If the tests don’t indicate a
cognitive disorder, it doesn’t immediately mean that there is no brain injury or disorder.
Reliability
The reliability of a test refers to the accuracy of the instrument.
Test-retest reliability: indicates the extent to which a test yields the same results when it is
taken at different times by the same patient. It is indicated by a correlation coefficient.
Inter-rater reliability: indicates the correspondence between the results of the same test
administered by various researchers and is presented as Cohen’s kappa.
2
,Validity
The validity answers the question whether the test measures what it is supposed to measure. Only
because a test measures what it is supposed to measure (face validity) doesn’t mean that it predicts
the patient’s function in everyday life (ecological validity).
Face validity: the extent to which a test initially measures what it is supposed to measure.
Content validity: the extent to which a test is representative of the topic that is to be
measured.
Construct validity: the extent to which the result of a test reflects the cognitive function (the
construct) that is being assessed.
Criterion validity: the extent to which a test can predict the performance of a patient about
an external criterion (e.g. social performance).
o Predictive validity: how accurately a test predicts actual behavior
o Concurrent validity: the difference between a neuropsychological test and another
tool that aims to measure the same criterion.
Ecological validity: the extent to which a test predicts the patient’s daily functioning.
Underperformance can happen when someone is very tired, nervous, has complaints or anxiety
during the test or simulates or exaggerates cognitive complaints. When this won’t be noticed this
can lead to a wrong diagnosis of a disorder which can have adverse consequences for the patient
and society. Underperformance should be considered when a patient performs better on challenging
tasks than on easy ones and if a striking discrepancy between behavior and test performance occur
and/or if the patient’s complaints are not in accordance with the severity of the disorder. Sometimes
underperformance is intentional. When given a multiple choice test underperformance is indicated
when a score lies significantly below the level achieved by chance (Test Of Memory Malingering).
The neuropsychologist in…
… hospitals. In this institution the neuropsychologist has to carry out neuropsychological diagnostics:
to identify the cause of a complaint or to assess the effects of a recognized brain injury. Treatment is
often short-term, complaint-oriented and it usually implies psychoeducation. They also advise
nursing teams when dealing with challenging behavior in patients with a brain injury. They assess the
effectiveness of a treatment or intervention.
… rehabilitation centers. Neuropsychologists have a leading and coaching role in various treatment
teams for patients with a neurological disorder. The focus is more on treatment than on diagnostics,
though neuropsychological assessment is critical. Therapy in rehabilitation centers focuses not only
on cognitive disorders but also on coping mechanisms and complaints such as depression or anxiety.
… mental health care. Neuropsychologists play an essential role in drawing up a treatment plan.
They are also involved in meditative treatment, in which they try to influence the patient’s behavior
via the people who are most closely involved with the patient. These psychologists mostly encounter
patients with mood disorders, psychotic disorders, ADHD, addiction and autism spectrum disorder.
… residential homes, nursing homes, and supported housing. The main tasks of a neuropsychologist
are evaluating cognitive skills, exploring the cause and expected course of complaints, giving advice
about suitable living and care arrangements and showing possible ways of influencing behavior.
Treatment methods range from cognitive rehabilitation, psychotherapy, systemic therapy for
supporting families or couples, meditative therapy, and practical advice for carriers.
… forensic institutions. There is a neurobiological basis for ‘criminal’ behavior. Referral questions are
usually related to explanatory diagnostics or are used to support a treatment assessment. The
criteria for reporting are very strict, because a diagnosis can influence custody of the patient.
3
, Korsakoff’s Syndrome and Alcohol-related
Cognitive Disorders
- Chapter 18 -
This lecture:
Discuss Korsakoff’s syndrome and other disorders caused by alcohol abuse
Korsakoff’s syndrome is a condition caused by a serious vitamin B1 (thiamine) deficiency
Korsakoff’s syndrome is usually the result of alcohol addiction
Patients primarily lose the ability to learn new information, but are also increasingly unable to
perform their normal daily routine and to care for themselves.
Summary:
Chronic alcohol use can result in severe brain damage which leads to cognitive deterioration of
varying severity.
An additional vitamin B1 (thiamine) deficiency may result in Korsakoff syndrome, with severe
amnesia and executive impairments.
Heavy drinkers are more likely to develop executive problems and cerebrovascular
complications.
DSM-5 classification of Korsakoff syndrome emphasizes amnesia or confabulations, though most
patients also have executive problems.
A thorough analysis of cognitive impairments and psychological functioning in addition to
neuroimaging should be conducted to find explanations for the impairments of the patient.
Epidemiology
The average age of people requesting help with alcohol-related problems is around 45 years, and
75% of those people are male. Only a few people under the age of 25 seek help with alcohol use
disorder (AUD) (5%). Only 20% of patients who seek help at addiction treatment centers are there
for the first time. Alcohol-related problems are sometimes combined with other problematic drug
use or gambling addiction. Long-term and excessive alcohol consumption can result in cognitive
impairments that may be present long before alcohol-related neurological symptoms appear. These
impairments are the results of the alcohol damaging the nervous system in various ways:
Immediate neurotoxic effect on neurons and axons;
Indirect neurotoxic effects of high calcium concentrations in the neurons after
sudden withdrawal of alcohol;
Irreversible disruption of physiological processes caused by chronic vitamin
deficiency (especially thiamine).
Direct changes in cognitive functioning after alcohol consumption include increasing reaction time.
this is not necessarily bad (so when it isn’t structural use), it happens all the time with a lot of
people that are using alcohol.
Changes in cognitive functioning after excessive alcohol consumption affect explicit memory and
prospective memory. this isn’t normal anymore. You have to use it excessively for a longer
period. The ability to perceive and judge emotions and emotional facial expressions is decreased, as
well as response inhibition and behavioral control.
Neurotoxicity of alcohol
Alcohol has a sedating effect on brain functioning through stimulating effect on the GABA-system
and an inhibitory effect on NMDA-receptors of the glutamate-system. The stimulating effect on the
4
